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Full text of "The American journal of the medical sciences"

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THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES 



No. XXIX.— November, 18S4. 1 



COLLABORATORS. 



Jacob Bigelow, M. D. Professor of 
Materia Medica in Harvard Univer- 
sity ^ Boston. 

Edward H. BARxoif, M. D. of New 
Orleans. 

Henht Bronson, M. D. of Mhany^ New 
York. 

Walter Channikg, M. D. Professor of 
Midwifery and Legal Medicine in 
Harvard TJiiiversity , Boston. 

N. Chapman, M, D. Professor of the 
Institutes and Practice of Physic and 
Clinical Practice in the University of 
Pennsylvania. 

JoHif Redmajst Coxe, M. D. Professor 
of Materia Medica and Pharmacy in 
the University of Pennsylvania. 

D. Frais-cis Condie, M. D. of Phila- 
delphia. 

WiLiiAM C. Daniell, M. D. of Savan- 
nah, Georgia. 

William P. Dewees, M. D. Profes- 
sor of Midiuifery in the University of 
Pennsylvania. 

S. Henry Dickson, M. D. Professor of 
the Institutes and Practice of Medicine 
in the Medical College of the state of 
South Carolina. 

Benjamin W. Dudley, M. D. Profes- 
sor of Jinatomy and Surgery in Tran- 
sylvania University. 

KoBLEY DuNGLisoN, M, D. Professor of 
Materia Medica, Therapeutics^ Hy- 
giene, and Medical Jurisprudence, in 
the University of Maryland. 

GouvERNEUR Emerson, M. \) . of Phila- 
delphia. 

Paul F. Eve, M. D. Professor of Sur- 
gery in the Georgia Medical College. 

John W. Francis, M. D. Late Profes- 
sor of Obstetrics and Forensic Medi- 
cine in Rutgers Medical College, New 
York. 

W. W. Gerhard, M. D. of Philadelphia. 

William Gibson, M. D. Professor of 
Surgery in the University of Pennsyl- 
vania. 

R. E. Gn'iTTirii,M.'D. of Philadelphia. 
E. Hale, M. D. of Boston. 

Robert Hare, M. D. Professor of Che- 
mistry in the University of Pennsyl- 
vania. 
George Hayward, M. D. Professor of 
the Principles of Surgery and Clini- 



cal Surgery in Harvard University, 
Boston. 

Thomas Henderson, M. D. Professor 
of the Theory and Practice of Medi- 
cine in the Columbian College, Dis- 
trict of Columbia. 

William E. Horner, M. D. Professor 
of Anatomy in the University of 
Pennsylvania. 

David Hosack, M. D. Late Professor 
of the Institutes and Practice of Medi- 
cine in Rutgers Medical College, New 
York. 

Ansel W. Ives, M. D. of New York. 

Samuel Jackson, M. D. Assistant to the 
Professor of the Institut es and Practice 
of Medicine and Clinical Practice in 
the University of Pennsylvania. 

Samuel Jackson, M. D. of Northum- 
berland, Pennsylvania. 

Valentine Mott, M. D. Professor of 
Pathological and Operative Surgery 
in the College of Physicians and Sur- 
geons, New York. 

James Moultrie, Jr. M. D. Professor 
of Physiology in the Medical College 
of the state of South Carolina. 

Reuben D. Mussey, M. D. Professor 
of Anatomy and Surgery in Bart- 
mouth College, New Hampshire. 

T. D. Mutter, M. D. of Philadelphia. 

R. M. Patterson, M. D. Professor of 
Natural Philosophy in the University 
of Virginia. 

Philip Syng Phtstck, M. D. Profes- 
sor of Anatomy in the University of 
Pennsylvania. 

Thomas Sewall, M. D. Professor of 
Anatomy and Physiology in the Co- 
lumbian College, District of Columbia, 

Ashbel Smith, M. D. of Salisbury, 
North Carolina. 

A. F. Vache, M. D. ofNeiv York. 

John Ware, M. D. Assistant Professor 
of the Theory and Practice of Physic 
in Harvard University, Boston. 

John C. Warren, M. D. Professor of 
Anatomy and Surgery in Harvard 
University, Boston. 

J. Webster, M. D. Lecturer on Ana- 
tomy and Surgery, New Yo7'k. 

Thomas H. Wright, M. D. Physician 
to the Baltimore Alms- House Injir- 
mary. 



EDITOR— Isaac Hays, M. D. 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



VOL. XV. 



PHILADELPHIA: 
CAREY, liEA & BliANCHARD. 

1834?. 






TO READERS AND CORRESPONDENTS. 



k 



Communications have been received from Drs. Waddell, Steel, Heustis, 
Pexkock, Horner and Young. 

We have not yet seen Dr. Hayward's Physiology. The copy sent by the 
author has not reached us. 

The following works have been received: — 

Researches on the Pathology and Treatment of some of the most important 
Diseases of Women. By Robert Lee, M. D., F. R. S., Physician Accoucheur 
to the British Lying-in Hospital, &c. 5cc. (From the author.*) 

Lecons de Chnique Medicale, faites a I'Hotel-Dieu de Paris. Par Le Profes- 
seur A. F. Chomel, recueilUes et publiees sous ses yeux. Par J. L. Genest, 
D. M. P. Ancien chef de Clinique Medicale de I'Hotel-Dieu de Paris, &c. 
(Fievre Typhoide.) Paris, Germer Bailhere, 1834. (From the publishers.) 

An Inquiry into the Principles and Practice of Medicine, founded on original 
Physiological Investigations. By G. Calvert Holland, M. D. Physician to the 
Sheffield General Infirmary. Vol. I. London, 1834. (From the author.) 

General Observations respecting Cholera Morbus. By J. N. Casanova, 
C. M. D. &c. &c. Philadelphia, 1834. (From the author.) 

An Introduction to the Study of Human Anatomy. By James Paxton, M. R. 
C. S. &c. Vol. II. First American Edition, w^ith Additions. By Winslow 
Lewis, Jr. M. D. Demonstrator of Anatomy to the Medical Department of Har- 
vard University. Boston, 1834. Allen Sc Ticknor. (From the publishers.) 

An Inquiry into the Claims of Dr. William Harvey to the Discovery of the 
Circulation of the Blood; with a more Equitable Retrospect of that Event. To 
which is Added an Introductory Lecture, Delivered on the 3d of November, 
1829, in Vindication of Hippocrates from Sundry Charges of Ignorance prefer- 
red against him by the late Professor Rush. By John Redman Coxe, M. D. Pro- 
fessor of Materia Medica and Pharmacy in the University of Pennsylvania, &c. 
&c. Philadelphia, 1834. (From the author.) 

A Compendium of Operative Surgery intended for the Use of Students, and 
Containing Descriptions of all Surgical Operations. Illustrated with Engravings. 
By Thomas L. Ogier, M. D. Lecturer on Anatomy and Operative Surgery, 
and Thomas M. Logan, M. D. Lecturer on Materia Medica and Therapeutics., 
No. 1. Charleston, 1834. (From the authors.) 

Documents Relative to the Massachusetts State Prison. (From J. Porter, Esq.) 
Case of Notencephale, with Engravings. By Charles T. Hildreth, M. Do 
Boston, 1834. (From the author.) 

Promotion of Health in Literary Institutions. New Haven, 1833. (From Henry 
Bronson, M. D.) 

Archives Generales de M^decine, for January, February and March, 1834. 
(In exchange.) 
Annales de la Medecine Physiologique, for February, 1834. (In exchange.) 

• This work, sent to us upwards of a year since, only i*eached us just as this sheet was going to press , 
We shall notice it in our next. 

1* 



VI TO READERS AND CORRESPONDENTS. 

Revue Medicale Francalse et etrangere, Journal des Progres de la Medecine 
Hippocratique, for January, February, March and April, 1834. (In exchange.) 

Journal de Chimie Medicale, for March and April, 1834. (In exchange.) 

Journal des Connissances Medico-Chirurgicale, January, February, March, 
April and May, 1834. (In exchange.) 

Journal Hebdomadaire des Progres des Sciences et Institutions Medicales. 
Vol. I. and Vol. II. No. XIV to XX. (In exchange.) 

Journal de Pharmacie et des Sciences Accessoires, for December, 1833, and 
January, February, March and April, 1834. (In exchange.) 

Gazette Medicale de Paris. March, April and May, 1834. (In exchange.) 

La Lancette Frangaise, Gazette des Hospitaux, Civils et Militaires. March, 
April and May, 1834. (In exchange.) 

The Edinburgh Medical and Surgical Journal, for July, 1833. (In exchange.) 

The Medico-Chirurgical Review, for July, 1833. (In exchange.) 

The London Medical and Physical Journal, for June and July, 1833. (In ex- 
change.) 

The London Medical and Surgical Journal, for June and July, 1833. (In ex- 
change.) 

London Medical Gazette, for July, August and September, 1834. (In ex- 
change.) 

Bibliothek for Laeger, No. 4, for 1832; Nos. 1, 2, 3, and 4, for 1833, and No. 
1, for 1834. (In exchange.) 

The Transylvania Journal of Medicine and the Associate Sciences. Vol. VII. 
Nos. 2 and 3. (In exchange.) 

The Boston Medical and Surgical Journal, Vol. X. No. 25. (In exchange.) 

The United States Medical and Surgical Journal, Vol. I. No. 1. (lu exchange.) 

The Medical Magazine, Vol. III. Nos. 1 to 6, 1834. (In exchange.) 

The Western Journal of the Medical and Physical Sciences, for April, May 
and June, 1834. (In exchange.) 

The Western Medical Gazette, for July, August and September, 1834. (In 
exchange.) 

The North American Archives of Medical and Surgical Sciences, for October,. 
1834. (In exchange.) 

For the gratifications of our contributors, we present references to the 
works, in which their communications are noticed. 

Professor Mott will find his case of Aneurism of the Right Subclavian no- 
ticed in the Gazette Medicale de Paris, for February 22d, 1834, Revue Medi- 
cale, for March, 1834, Journal de Connais. Med. Chirurg. for May, 1834; and 
his Case of Extirpation of Parotid Gland, in the Bibliothek for Lseger, No. 2, 
1833. 

Professor Gibson will find his Case of Tumour of the Neck noticed in La 
Lancette Frangaise for April 13th, 1834. 

Professor Geddings's Case of Fungous Haematodes of the Thigh, is noticed 
in the Journal Universel et Hebdomadaire for November, 1833. 

Professor Horner's Experiments on the Vascular Connexion of the Mother 
and Foetus, are noticed in the Journ. des Connaiss., Med. Chirurg. for Novem- 
ber, 1833, Gaz. Med. de Paris, for February 22d, 1834, Archives Generales for 
February, 1834; and his Case of Hepatic Abscess is copied in the London Med. 
and Surg. Journ. for August, 1834. 



TO READERS AND CORRESPONDENTS. VU 

Di*. jACKSoJf's Remarks on the Use of Cold Water in Scarlatina, are noticed 
in the Rev. Med. for September, 1833, London Med. and Surg. Journ. for 
July, 1833; and his Observations on the Efficacy of Belladonna in Pertussis, are 
noticed in the Western Med. Gaz. for September, 1834. 

Dr. Mitchell's Paper on Rheumatism, is noticed in the Gaz. Med. for 
February 22d, 1834, Rev. Med. for January, 1834, and in the United States 
Med. and Surg-. Journ. for August 1st, 1834. 

Dr. Harris's Cases of Neuralgia Treated by Galvanism, are copied into the 
Transylvania Journal for October, 1834. 

Dr. RoBiNsoiir's Case of Monstrosity, is noticed in the Archiv. Gen. for Ja- 
nuary, 1834, Journ. Univ. et Hebdom. November, 1833, and London Med. and 
Surg. Journ. June, 1833. 

Dr. Williams's Paper on the Medicinal Uses of the Viola Ovata, is noticed in 
the Philadelphia Journal of Pharm. for April, 1834; his Remarks on the Use of 
the Conium Maculatum in Affections of the Mammae, are noticed in the Bib- 
liothek for Laeger, No. 4, 1833, and in Behrend's Repertor. for 1833; and his 
Case of Stricture of Vagina in the London Med. and Surg. Journ. for July, 1834. 

Dr. Bond's Account of the Post Mortem Examination of a Female who died 
shortly after Coitus, is noticed in the Gaz. Med. de Paris for April 19th, 
1834, Journ. Hebdom. May 10th, 1834, Medical Magazine for March, 1834, and 
La Lancette Francaise for April 12th, 1834. 

Dr. Roger's Case of Ligature of Common Carotid for Anastomosing Aneu- 
rism, is noticed in the London Med. Review for January, 1834; and his Case of 
Ossification of the Muscular Tissue in the Gaz. Med. for April 19th, 1834. 

Dr. Wright's Contributions to Cardiac Pathology, are noticed in the Trans. 
Medicales for November, 1833, and in the Rev. Med. for January, 1834. 

Dr. Hulse's Case of Ununited Fracture, is noticed in the Gaz. Med. de Paris 
for April 19th, 1834, and in the Dublin Journal, for September, 1834. 

Dr. Heustis's Case of Prolapsus Recti treated by Excision is copied in the 
London Medical and Surgical Journal, June, 1833. 

TiCKi^fOR's Anomalous Case is noticed in the Boston Medical and Surgical 
Journal for October 15th, 1834, and the Lond. Med. and Surg. Journ. for Au- 
gust, 1834. 

Tolefkee's Observations on the Circular and Flap Operations are noticed in 
the Med. Magazine for March, 1834, and in the Gaz. Medicale for April 19th3 
1834. 

Chakn^ing's paper on the lodo-hydrargyrate of Potassium is noticed in the 
Phil. Journ. of Pharm. for April, 1834, and in the Gaz. Med.de Paris for April 
19th, 1834. 

Dr. Griscom's Memoir on the Apocynum Canabinum is noticed in the Ar- 
chives Gen. for October, 1833, Journ. de Chim. Med. for February, 1834, and 
in the Journ. de Pharm. for February, 1834. 

Dr. Fahnestock's Case of Partial Congestion of the Cerebrum is noticed in 
the Rev. Med. for September, 1833, and in the Journ, Univ. et Hebdom. for 
November, 1833. 

Dr. Ward's Case of Vagitus Uterinus is noticed in the Rev. Med. for Sep- 
tember, 1833. 

Dr. Barrington's paper on Yellow Fever is noticed in the Gaz. Med. for 
February 22d, 1834. 



VIU TO READERS AND CORRESPONDENTS. 

Dr. Hodge's paper on Puerperal Fever is noticed in the Gaz. Med. for Fe- 
bruary 22d, 1834. 

Dr. Zoxlickoffek's paper on the Apocynum Canabinum is noticed in the 
Gaz. Med. for February 22d, 1834. 

Dr. Harden's Case of Shoulder and Arm Presentation is noticed in the Gaz. 
Medicale for February 22d, 1834, in the Rev. MTd. for January, 1834, and in 
the Journ. de Conna ss. M^d. Chirurg". for May, 1834. 

Dr. Ateee's paper on Hydrocyanic Acid in Pertussis is noticed in La Lancette 
Frangaise for October 10th, 1833. 

Dr. Gillespie's Case of Luxation of the As'ragalus is noticed in the Journ. 
Univ. et Hebdom. for November, 1833, and his Cases of Neuralgia are copied 
into the London Med. Gaz. for August, 1834. 

Dr. Tkowbbidge's Case of Calcareous Incrustation of Bladder is noticed in 
the Journ. Univ. et Hebdom. for January 25th, 1834. 

Dr. Linbslet's Observations on Amenorrhoea are noticed in the Gaz. Medi- 
cale for April 19th, 1834. 

Dr. Wallace's note on a New Membrane of the Eye is noticed in the Gaz. 
Med. de Paris for April 19th, 1834. 

Dr. Zabhiskie's Case of CEsophagitis is noticed in the Gaz. Medicale for April 
19th, 1834, and his Case of Amnesia in the Dublin Journal for September, 1834. 

Dr. Charlton's Case of Incongruous Twining, is copied in the Medical Ga- 
zette for August, 1834. 

Dr. Young's paper on Cimicifuga racemosa in Chorea, is noticed in the Bib- 
liothek for Leeger, No. 3, 1834, and his Case showing the Effects of Lightning, 
and his Case of Poisoning with Laudanum, are copied in the Medical Gazette 
for August, 1834. 

Dr. PicTOJT on the Influence of Light in preventing Pitting in Small-pox, is 
noticed in the Bibhothek for Lseger, No. 3, 1834. 

Dr. Lebeau's Case of Premature Puberty, is noticed in Froriep's Notizen, No. 
3, 1834. 

Dr. Worrell's Case of Adhesion of Placenta to Fundus of Uterus, is noticed 
in the Dublin Journal for September, 1834. 

Dr. Harris's Cases of Yellow Fever are noticed in the Transylvania Journal 
for October, 1834. 

Dr. Huston's Case of Hypertrophy of Mammae is copied into the Transylva- 
nia Journal for October, 1834. 

Authors of new medical books, desirous of having them reviewed or noticed 
in this Journal at the earliest opportunity, are invited to transmit to the Editor 
a copy as soon after publication as convenient, when they will receive prompt 
attention. Under ordinary circumstances, very considerable delay is caused by 
the circuitous routes through which they are received. 

Papers intended for publication, should be sent, /ree of expense, as early after 
the appearance of the Journal as possible, in order to be in time for the ensuing 
number. Such communications should be addressed to ** Caret, Lea & Blan- 
CHARD, Philadelphia, for the Editor of the American Journal of the Medical 
Sciences." 

All letters on the business of the Journal to be addressed exclusively to the 
publishers. 



CONTENTS 



ORIGINAL COMMUNICATIONS. 

ESSAYS. 
Abt. Page. 

I. Account of Six Cases of Stone in the Bladder, in which the Operation 
of Lithotripsy was Successfully performed. By J. Randolph, M. D. one 

of the Surg-eons to the Philadelphia Alms-house Infirmary - - 13 

II. Account of the Epidemic Yellow Fever which prevailed in New Or- 
leans during the Autumn of 1833. By Edward H. Barton, M. D. - 30 

III. Report of Cases treated in the Pennsylvania Hospital. By T. S. Kirk- 
bride, M. D. one of the Resident Physicians 64 

IV. Observations on Nightmare. By Blanchard Fosgate, M. D. of Auburn, 

N. Y 80 

V. Pneumonia of Children. By AV. W. Gerhard, M. D. [Part 2d.] - 87 

VI. On the Permanent Adhesion or Incorporation of the Placenta with the 
Substance of the Uterus. By J. W. Heustis, M. D. of Alabama - 106 

VII. Remarks on Cases of Retained Placenta. By T. I. Charlton, M. D. of 
Bryan County, Georgia •- 113 

VIII. Description of a New Splint for Fractured Clavicle. By E. C. Kecke- 
ley, M. D. of Charleston, S. C. [Communicated in a letter to the Editor] 115 

IX. On the Vis Medicatrix Nature. By John Dickson, M. D. - - 116 

X. Observations on the Treatment of Gun-shot Wounds, Ulcers, &c. By 
Paul F. Eve, M. D. Professor of Surgery in the Medical College of 
Georgia 120 

XI. Case of Wound of the Genitals. By James B. M'Junkin, of Lexington, 
Georgia. [Communicated by S. H. Dickson, M. D. Professor of the 
Institutes and Practice of Medicine in the Medical College of the State 

of South Carolina] - - 123 

REVIEWS. 

XII. Surgical Essays, the result of Clinical Observations made at Guy's 
Hospital. By B. B. Cooper, F. R. S., Surgeon to Guy's Hospital, Lec- 
turer on Anatomy, &c. &c. &c. London, 1833. pp. 281, 8vo. - - 125 

XIII. Lecons de Clinique Medicale faites a I'Hotel-Dieu de Paris, par le Pro- 
fesseur A. F. Chomel, Recueillies et Publiees sous ses yeux, par J. L. 
Genest, D. M. P., Ancien chef de Clinique Medicale de I'Hotel-Dieu, 
&c. (Fievre Typhoide.) 8vo. pp. 548. Paris, 1834 - - - 137 

BIBLIOGRAPHICAL NOTICES. 

XIV. An Inquiry into the Claims of Dr. William Harvey to the Discovery 
of the Circulation of the Blood; with a more Equitable Retrospect of 
that Event. To which is added an Introductory Lecture, delivered on 
the 3d of November, 1829, in Vindication of Hippocrates from Sundry 
Charges of Ignorance, preferred against him by the late Professor Rush. 
By John Redman Coxe, M. D., Professor of Materia Medica and Phar- 
macy in the University of Pennsylvania, &c. &c. De mortuis nil, nisi- 
verum. Philadelphia, 1834. 8vo. pp. 258 153 

XV. The Cyclopedia of Practical Medicine and Surgery; a Digest of Medi- 
cal Literature. Edited by Isaac Hays, M. D., &c. Parts Hi., IV. and V 157 

XVI. De la Reunion Immediate des Plaies, de ses Advantages et de ses In- 
convenients. Par L. J. Sanson, Chirurgien de I'Hotel-Dieu de Paris. 
Paris, 1834. pp. 115 159 

XVII. Jurisprudence de la Medecine, de la Chirurgie, et de la Pharmacie, 
en France; comprenant la Medecine Legale, la Police Medicale, la Res- 
ponsabilite des Medecins, Chirurgiens, Pharmaciens, &.C.; I'Expose et la 
Discussion des Lois, Ordonnances, Reglemens et Instructions concernant 
I'art de guerir; appuy^ des Jugemens des Cours et des Tribunaux. Par 
Adolphe Trebuchet, Avocat, Chef du Bureau de la Police Medicale et 



10 



CONTENTS. 



Page. 



Paris, 1834. pp. 



168 



iro 



172 



Aht. 

des ^tablissemens insalubres a la Prefecture de Police. 
756. 8vo. 

XVIII. Arzeimittellehre und Receptirkunde zum Behiife der Vorlesungen, 
entworfen von Emanuel Stephan Schroff, der Heilkunde Doktor und 
Professor der Theoretischen und Praktischen Medicin fiir Wundarzte an 
der k. k, Medicinisch-Chirurgischen Josephs-Akademie, und Karl Damian 
Schroff, der Heilkunde Doktor und Professor der Theoretischen Medicin 
fiir Wundarzte an der k. k. Universitat zu Olmiitz. pp. 428. 12mo. 
Wien, 1833 

XIX. 1831 — Jahres-Bericht ueber das Clinische Chirurgisch-aug"enarztliche 
Institut der Universitat zu Berlin, abg-estatet vom Director der genannten 
Anstalt Dr. Carl Ferdinand von Graefe, &c. Funfzehnte Folge, 4to. pp. 
34. Berlin, 1832 

XX. De I'Operation du Trepan dans les Plaies de Tete. Par A. A. M. L. 
Velpeau, Chirurgiendel'HopitaldelaPitie. Paris, 1833. pp.274. Octavo 173 

XXI. A Compendium of Operative Surgery, intended for the Use of Stu- 
dents, and containing a Description of all Surgical Operations. Illustrated 
with Engravings. No. 1. By Thomas L. Ogier, M. D. Lecturer on Ana- 
tomy and Operative Surgery, and Thomas M. Logan, M. D. Lecturer on 
Materia Medica and Therapeutics. Charleston, 1834. pp. 262 

XXII. Du Cholera-Morbus en Russie, en Prussie et en Autriche, pendent 
les annees 1831 et 1832. Par M. M. Auguste Gerardin et Paul Gaimard, 
Membres et Commissaires de 1' Academic Roy ale de Medecine, Envoyes 
en Russie par le Gouvernement Francais, pour Etudier le Cholera. 
Deuxeme edition. Avec trois Planches gravees et coloriees, &c. &c. 
Paris, 1832. pp.340. 8vo. 

XXIII. General Observations respecting Cholera Morbus. By J. N. Casa- 
nova, C. M. D. of the Royal College of Medicine of Cadiz. Philadelphia, 
Carey & Hart. pp. 173. 8vo. , . . - . 



179 



181 



188 



QUARTERLY PERISCOPE. 

FOREIGN INTELLIGENCE. 



Anatomy. 



Page. 

1. Some points in the Anatomy, 
Physiology, and Pathology of 
the Vertebral Column. By M. 
Chassaignac - - . 190 

2. Communication of the Optic 
Nerves. By M. Nelaton - 191 

3. Situation of the Decussation of 



Page. 
the Anterior Cords of the Me- 
dulla Oblongata in relation to 
the Occipital Foramen - 191 

4. M. Camus on the Nerves of the 
hand ----- ih. 

5. Hermaphrodite - - ib. 



Phtsiologt. 



6. M. Majendie's Experiments 
upon the Sounds of the Heart 192 

7. On the Relations of the Cranium 
to the Organ of Hearing. By 
Professor Mojon - - 193 

8. On the Question of Venous Ab- 
sorption. By Dr. Luchtmans 194 

9. Structure and Functions of the 
Skin. By MM. Breschet and 
Roussil de Vauzeme - 198 

10. Passage of Gases through Li- 
quids. By M. Dutrochet - 199 

11. Influence of Gravity, and of a 



Depending Position on the Cir- 
culation of the Blood, in Health 
and in Disease ... 200 

12. Of the Chemical Properties 
of the Secretions in Health and 
Disease, and of the existence of 
Electrical Currents determined 
in Organized Bodies by the 
Acidity and Alkalinity of the 
Membranes. By M. Donne 203 

13. Action of Sugar upon Human 
Blood. By Professor Hegewisch 205 



CONTENTS. 



11 



Pathology. 



Page. I 

14. Case of Foreign Body found 
in the Heart of a Boy. By T. 
Davies, Esq. - - - 205 

15. Cases Illustrating the Termi- 
nations of Ovaritis Puerperalis 206 

16. Fatal Case of Effusion of Blood 
into the Pericardium. By Dr. 
Carson .... 207 

17. Case of Extensive Mesenteric 
Disease — Great Heat of the 
Whole Body the Chief Symp- 
tom - - - - 210 

18. Case of Paraplegia — Sup- 
pression of the Urinary and 
Anal Evacuations During Eleven 
Years. By Dr. Montesanto ib. 

19. Case of Apparent Death 
[Life?] which lasted Three 
Weeks. By Dr. Schmidt - 211 

20. Cyst in the Brain. By M. Ver- 
nois ib. 

21. Acute Rheumatism termi- 
nating in Suppuration. By MM. 
Guersent and Dance - - 212 

22. On Cancer of the Stomach. 

By William Stokes, M. D. ib. 



Page. 

23. On Duodenitis. By William 
Stokes, M. D. - - - 214 

24. On Inflammation of the Jeju- 
num. By William Stokes, M. D. ib. 

25. On Inflammation of the Ileum, 

By William Stokes, M. D. - 215 

26. Inflammation of the Ileum in 
Children. By William Stokes, 

M. D. .... 217 

27. On Tabes Mesenterica. By 
Wilham Stokes, M. D. - 219 

28. On Diseases of the Large In- 
testines. By William Stokes, 

M. D. .... 221 

29. On Dysentery. By William 
Stokes, M. D. - - - ib. 

30. Case of Destruction of the Cen- 
tral Substance of the Spinal Mar- 
row. By M. Maisonneuve - 222 

31. Cartilages not Susceptible of 
Inflammation. By M. Cruveil- 
hier ib. 

32. Serous Apoplexy - - ib. 

33. Seat and Nature of Gonor- 
rhoeal Orchitis. By Dr. Marc- 

Moreau . - - . ib. 



Semeiologt. 



34. Foramen Ovale remaining 
Open in the Adult - - 223 

S5. Case of Aneurism of the Aorta 
simulating Laryngeal Phthisis ib. 

26. Case of Ossification of almost 
the whole extent of the Aorta 
and Pulmonary Artery taken for 
an Aneurism of the Heart ib. 



37. Particular Sound of the Heart. 

By Professor Puchelt - 224 

38. Case of Softening of the Spi- 
nal Marrow simulating x\neurism 

of the Heart - - - ib. 

39. Pulmonary Tubercles simu- 
lating an Affection of the Heart. 

By M. Huguier - - ib. 



Materia Medica. 



40. Lotions for the Cure of Porri- 

go Favosa. By M. Dauvergne 224 

41. Properties and Effects of the 
Digitalis Purpurea. By M; Joret 225 

Practice of 

45. Treatment of Ileitis. By Wil- 
liam Stokes, M. D. - - 228 

46. Treatment of Diarrhoea. By 
William Stokes, M. D. - 234 

47. Inhalations of Chlorine in 
Phthisis. By M. Toulmouche 238 

48. Tartar Emetic in Frictions as 
a Means of producing Resolu- 
tion. By M. Yvan - - ib. 

49. Pruritus. By Dr. Carron-du- 
Villards .... ib. 

50. Swelled Breasts - - ib. 



42. Ointment for the Cure of Por- 
rigo. By M. Biett - - 225 

43. M. Soubeiran onRhatany Root ib. 

44. Syrup of Aspai-agus. By A. 
Latour and Roziers - - 227 

Medicine. 

51. Incurable Neuralgia of the Ul- 
nar Nerve. By Professor Viviani 239 

52. Mercurial Inunctions in the 
Treatment of Paronychia. By 

M. Serre D'Alais - - ib. 

53. Soot in Cutaneous Diseases. 
ByM.Blaud - - - ib. 

54. On the Use of the Phosphoric 
Acid in the last Stage of Croup. 

By M. August Boyer - - 240 

55. Bigonia Catalpa in Asthma ib. 

56. On the Employment of Chlo- 



12 



CONTENTS. 



Page. 
ride of Lime and Soda in some 
Affections of the Mouth,common 
in Children. By Dr. Constant 240 
5T. On the Employment of Chlo- 



Page. 
ruret of Lime in Itch. By Dr. 
Hospital .... 240 
58. On the External Use of Cro- 
ton Oil. By Professor Andral ib. 



Ophthalmologt. 



59. On the Use of Soot in Diseases 
of the Eyes. By M. Carron-du- 
Villards - - . - 243 

60. OftheCapsulo-Lenticular Re- 

SURGEBT. 



clination, or New Method of De- 
pressing- Cararact with a New 
Needle. By M. Bergeon - 244 



61. New Method of Extracting 
the Stone from the Bladder, by 
a Perinseal Incision. By Dr. Ma- 
riano Pantaleo - - . 247 

62. Treatment of Club-foot, by 
Dividing the Tendo-achillis; a 
new Operation. By Dr. Louis 
Stromeyer _ . . H, 

63. Case of Subcutaneous Vascu- 
lar Naevus. By W. C. Worthing- 
ton, Esq. - - - - 251 



64. Case of Imperforate Anus ex- 
isting for Two Months. By M. 
Caussade - - . . 251 

65. Case of Successful Treatment 
of Disunited Fracture by the 
Tourniquet - - _ H, 

66. Luxations of the Humerus. 

By M. Gerard - - - 252 

67. New Pad for Trusses. By MM. 
Cresson and Sanson - - ib. 



Midwifeht. 



68. Case of Rupture of the Va- 
gina during Delivery - 252 

69. Injections of Cold Water into 



the Umbilical Cord to Promote 
the Separation of the Placenta. 
By Professor Hohl - - 252 



Chemistry. 



70. On a New Alkaloid Substance 
called Quinodine discovered in 



72. Beaumont's Experiments 254 

73. Examination of the Trials 
made with Homoeopathic Medi- 



Yellow Bark. By MM. Henry 
and A. Delondre - - 253 

71. New Ether. By M. Pelouze 254 

MlSCEIXANEOUS. 

cine in the Military Hospital of 
St. Petersburgh. By Dr. Seidlitz 254 
74. Death of St. John Long - 255 



AMERICAN INTELLIGENCE. 



Account of the Cholera in New 
York during the present year. 
By C. A. Lee, M. D.— [Commu- 
nicated in a letter to the Editor] 256 

Twelve Cases of Poisoning by Ar- 
senic in the Same Family. By 
W. G. Ramsay, M. D. of Charles- 
ton, S. C. ... 259 

Description of a New Form of the 
Stomach Pump. By P. B. God- 
dard, M. D. of Philadelphia 262 

Introduction of Air into the Veins. 
By Benjamin F. Wing, M. D. 264 

Luxation of Dentatus on Third 
Vertebra of the Neck. By Dr. 
A. J. Spencer, of Ticonderoga 265 



Case of Puberty and Pregnancy In 
a Girl of Ten Years of Age. By 
Dr. D. Rowlett, of Kentucky 266 

Ointment to Allay the Irritation of 
Hsemorrhoidal Tumours. By Dr. 
Geddings - - - ib. 

Contribution to History of Vacci- 
nation. By the Editor - 267 

Bill of Mortality of Philadelphia 
for the year 1833. With re- 
marks, by G. Emerson, M. D. ib. 

Salivation Arrested by Emesis. By 
Dr. Ezra Read - - - 274 

Paxton's Anatomy ... ib. 

University of Pennsylvania - ib. 

Advertisements - - - 275 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



Art. I. Actoiint of Six Cases of Stone in the Bladder, in which tlw 
Operation of Lithotripsy^ was Successfully performed. B j J. Ran- 
dolph, M. D. one of the Surgeons to the Philadelphia Alms-house 
Infirmary. 

A. DEGREE of surprise will probably be excited in the minds of 
some who read this paper, at my having so long delayed giving an 
account of the following cases, but I have been actuated by two mo- 
tives in withholding their publication; in the first place, I wished 
that a sufficient length of time should elapse to test fairly and fully 
the results of the operations, and in the second place, the several 
cases presented themselves so simultaneously, that I was unwilling 

* Baron Heurteloup, who has obtained the most triumphant success in the 
destruction of calculi in the bladder by means of percussion, effected through 
the agency of an instrument invented by himself, which he calls " Le Percuteur 
courbe a Marteau," has adopted, and I think with great propriety, the term 
lithotripsy in preference to that of lithotrity. He says, *^ Lithoiripsie veut dire 
pulverisation de la pierre, de xSoq pierre et de t(>iQoc, je pulverise, ^pi-lti, pulve- 
risation; il indique consequemment le but general de I'operation, sans indica- 
tion d'aucun precede. II n'en est pas de meme du mot lithotritie, qui n'a ja- 
mais designe que le precede detruire la pierre par des perforations repetees; 
en effet, il est derive de kiQo? pierre et de tn^dai ou TSfsa, je perce. On sent bien 
que I'on ne peut pas appeler lithotritie Taction d'un instrument qui ecrase les 
pierres ou celle qui les brise par la percussion. En un mot, la Uthotripsie est 
le nom donne a la methode prise en general, qui consiste a pulveriser les 
pierres, et le mot lithotritie n'indique que le precede de perforer successive- 
ment les pierres pour les detruire. Lithotripsie est le genre, lithotritie est 
I'espece." 
No. XXIX— November, 1834. 2 



14 Randolph's Cases of Lithotripsy. 

to give an account of one until the whole were completed. Had I, in 
truth, consulted merely my own feelings, it is probable that I should 
not even, at this period, have consented to the publication of this 
brief outline of the cases: to this step I confess I have been princi- 
pally induced by the advice of my valued friend, the editor of this 
Journal, who urged that the alleged success of the operations might 
be called in question unless an authentic report of them were made 
to the profession. 1 am well aware, indeed, that it has been stated, 
both publicly and privately, much to the opprobrium of American 
surgeons, that the operation of lithotripsy has never been successfully 
performed in this country; facts, however, are stubborn things, and 
the following will, I trust, furnish a sufficient refutation to all such 
rash assertions. 

Case I. The first patient on whom I performed the operation of 
lithotrity was Augustien, a French cook, aged fifty years, placed un- 
der my care by my friend, Dr. R. La Roche. Augustien had been 
afflicted with the symptoms of stone for about three years; had suf- 
fered at times very severely, and was seldom able to retain his urine 
for a longer period than from ten to fifteen minutes. 

Having properly prepared this patient for the operation, by the in- 
troduction of straight sounds into the bladder, not only for the pur- 
pose of accustoming the parts to the presence of instruments, but 
also to ascertain the exact situation of the stone, on the 22d of Sep- 
tember, 1832, I distended his bladder with barley water, and intro- 
duced into it the cannula containing the three-branched forceps and 
drill of M. CiviALE, (called lithotriteur,) in the presence of Drs. 
Horner and La Roche, and Messrs. Pile and Cooke. 

The instrument passed readily into the bladder, and immediately 
came in contact with the stone; I now protruded the blades of the 
forceps, and succeeded in catching the stone without the slightest 
difficulty; I next put the drill into motion by means of the bow, and 
perforated the stone in a very short time; its diameter appeared to 
be about two inches. It was now deemed proper to desist for the pre- 
sent; I accordingly liberated the stone, closed the blades of the for- 
ceps, and withdrew the instrument. 

The patient did not suffer severe pain from this operation, which 
occupied fifteen minutes. 

Upon withdrawing the instrument, a considerable portion of cal- 
culous matter came away with it; this was quite soft, and w^as found 
subsequently to be composed of the phosphate of lime; the same sandy 
matter also escaped after the operation along with the fluid and urine 
which he voided. 



Randolph's Cases of Lithotripsy, 15 

On the 29th of September I again introduced the instrument in the 
presenceof Drs. Physick, Horner, and La Roche, and Messrs. Pile 
and Cooke. Having, as on the former occasion, succeeded in catch- 
ing the stone without difficulty, I drilled a hole through it, which I 
soon perceived to communicate with the aperture made at the first 
operation. 

My next object was to turn the stone, which was accomplished 
with some slight difficulty, and another perforation was made through 
it. I now removed the instrument from the bladder, but experienced 
considerable embarrassment in doing this in consequence of the fine, 
soft sand mixed with the mucus forming a kind of mortar, which in- 
sinuated itself between the blades of the forceps and the drill, and 
adhered to them in such a manner as to prevent the blades from 
closing as completely as they ought to have done. 

Soon after the operation the patient took a warm bath, and voided 
the fluid contained in his bladder, together with a considerable quan- 
tity of calculous matter. 

From this period fragments of the stone continued to be voided for 
several days, and some of these were of considerable size, showing 
evidently that the stone was very much broken. 

On the 13th of October I repeated the operation in the presence of 
Drs. Physick, Horner, La Roche, and W. Rush, and Messrs, 
Pile and Cooke. On this occasion I used an instrument one size 
smaller than the one before employed, immediately caught the stone 
and bored a hole quite through it; I then attempted to change the posi- 
tion of the stone without letting it go from the forceps; this however I 
could not effect: I now expanded the blades of the forceps and liber- 
ated the stone, then placed the patient on his left side and caught 
the stone and drilled a hole through it which communicated wdth other 
apertures and seemed to break it up considerably. I now again liber- 
ated the stone and placed the patient on his right side, then caught 
it and made another perforation through it with the same efiect. 

It was now deemed proper to desist, the time occupied by this ope- 
ration being about twenty minutes. Soon after removing the instru- 
ment, the patient voided the fluid which had been injected into his 
bladder, and with it a good deal of calculous matter. In the evening 
he had some fever, vi^hich however passed oii* in the night by perspira- 
tion. The fragments of stone voided after this operation exceeded 
much in quantity that passed off after the two first operations. 

On the 16th he had a slight chill, which was followed by some fever 
and pain in the back; these symptoms yielded to two bleedings and a 
cathartic. 



16 Randolph's Cases of Lithotripsy, 

The fourth operation was performed on the 31st of October, in the 
presence of Drs. Horner and Rush, and Messrs. Pile and Cooke. I 
caught the stone very readily and made several perforations through 
it. He suffered very little from this operation; the instrument was 
introduced and withdrawn without causing any irritation; soon after 
it he took a warm bath and voided a considerable portion of calculous 
matter. 

Being fully satisfied from the quantity of stone collected after these 
several operations, and from its measurement by the forceps, that the 
remaining fragment was of small size, I endeavoured very carefully 
at this last operation to crush the fragment into pieces by means of 
the forceps; this attempt however did not prove effectual. 

I now determined to make trial of the instrument invented by Mr* 
Jacobson, of Copenhagen, for the purpose of breaking up a stone in 
the bladder, and accordingly on the 7th of November I introduced 
this instrument into the bladder in the presence of Dr. Horner and 
Mr. Cooke, and succeeded in a few minutes in catching the stone and 
breaking it into pieces. Upon withdrawing this instrument, which 
subsequent experience has induced me to consider one of the most 
valuable and important ever invented for surgical purposes, I had the 
satisfaction to find that its blades were completely filled with the cal- 
culous matter. The fragments continued to be discharged for several 
days after this operation; one piece of rather large size lodged in the 
urethra for near thirty-six hours, it did not however occasion sufiS- 
cient irritation to induce me to make any great effort either to push 
it back into the bladder, or to break it in the urethra; it was finally 
discharged, and the patient then expressed himself free from all pain 
of the stone. 

From this period the patient rested well at night, and was able to 
retain his urine for five or six hours; this fluid also which previously 
to the operations was exceedingly turbid and mixed with a considera- 
ble quantity of mucus, now became perfectly transparent and clear. 
Having subjected the bladder to a careful examination, and having 
sounded it repeatedly without detecting any particle of stone remain- 
ing, tliis case was reported cured on the 26th of November. 

It is proper I should state that four or five months subsequently to 
this period, Augustien again called upon me labouring under some of 
the symptoms of stone; I lost no time in introducing a sound into his 
bladder, and ascertained that there was a fragment within it; I intro- 
duced Jacobson's instrument twice, caught the piece immediately, and 
crushed it completely. 

These operations did not occupy more than a minute, and were 



Randolph's Cases of Lithotripsy, 17 

not productive of any irritation; he passed out the fragments in a few 
days, since when he has enjoyed good health, and attends to his ordi- 
nary concerns. 

Case II. Early in November, 1832, I was requested by Dr. Phy- 
sick to take charge of the case of Mrs. F. D. of Virginia, aged about 
twenty-seven years, wife of Col. D. Mrs. D. had been afflicted with 
the ordinary symptoms of stone for fourteen years. Soon after she 
arrived in this city Dr. Physick sounded her, and ascertained that 
there was a calculus of large size in the bladder. 

In consequence of her protracted and severe sufferings, Mrs. D. 
was at this period much emaciated and exceedingly nervous. So 
great, indeed, was the prostration of her system, that upon the day 
appointed for my first essay, Dr. Physick considered her to be too 
feeble to bear any attempt to be made to break the stone. 

Having by proper restoratives imparted more tone to her system, I 
commenced the operation on the 16th of November, in the presence 
of Dr. Physick. 

The irritability of the bladder in this instance was so great, that 
the patient could not bear any fluid to be injected into it, and ac- 
cordingly, without resorting to this expedient, I introduced the three- 
branched forceps of M. Civiale, and having expanded its blades, after 
considerable difficulty, I could only succeed in catching hold of a project- 
ing portion of the stone; I next put the drill into motion, and bored a 
hole, which only extended partially through the stone. Upon with- 
drawing the instrument, we ascertained that the stone was very soft, 
and I was now convinced that it was too large to be embraced by the 
forceps. Being provided with Jacobson's instrument, I next intro- 
duced this into the bladder, and succeeded in breaking off, from the 
sides of the stone, a considerable portion of calculous matter. This 
instrument was introduced and withdrawn without producing any 
pain; soon after the operation, which occupied only a few minutes, 
Mrs. D. voided large quantities of the stone, and continued to do so 
for five or six days; the amount collected seemed indeed sufficient of 
itself to constitute a calculus of tolerable size. From this period she 
recovered her health and spirits to a very great degree, and there 
was also a considerable abatement of the painful symptoms of her 
disorder. 

On the 26th of November I again introduced the instrument of 
Civiale in the presence of Dr. Physick. In a very short time I caught 
the stone and drilled a hole completely through it; I then expanded 
the blades of the forceps slightly, loosened the stone, changed its po- 
sition, and made another perforation through it. I next endeavoured 

2* 



IS R^Tidioii^h^s Cases of Lithotripsy. 

to break up the stone as much as possible, by pulling forcibly at the 
blades with the view of compressing them. It being now thought pro- 
per to desist for the present, I let the stone go and attempted to take 
out the instrument^ here however I met with the same difficulty I 
experienced in Augustien's case, on account of the soft stone adher- 
ing like mortar to the sides of the drill and forceps, and preventing 
the blades from closing entirely. This part of the operation caused 
considerable pain; when the instrument came out it brought with it 
a large quantity of sandy matter. Soon after the operation, Mrs. D. 
took a warm bath and passed a good deal of stone; she rested well 
at night, and the next day felt freer from pain than she had been for 
a long time. Mrs. D. continued to void calculous matter for five or 
six days after this operation, during which time her general health 
also improved considerably. 

On the 15th of December I again introduced the lithotripteur, and 
caught the stone, which proved to be much lessened in size. I made 
one perforation through it and then let it go, withdrew this instrument 
and introduced Jacobson's, and broke the calculus up, as I thought, 
completely. Mrs. D. did not suffer the least pain either during or 
after this operation; she voided the calculous matter as on the former 
occasions. 

Upon examining the bladder, however, four or five days subse- 
quently to this operation, I ascertained that there was a portion of 
stone remaining too large to pass through the urethra. 

On the 25th of December I introduced Jacobson's instrument, and 
caught the stone instantly and broke it, and caught it again and broke 
it; after this Mrs. D. passed out several large fragments which caused 
a good deal of straining, and on the 5th day a hcemorrhage occurred. 
The bleeding was stopped by keeping her perfectly still in a recum- 
bent posture, making cool applications to the vulva, and drawing ofi' 
the urine by means of a catheter, besides which she drank cool alum ' 
whey. From this period Mrs. D.'s sufferings were almost entirely re- 
lieved; it was found, however, upon examination, that a fragment 
was still in the bladder; for the purpose of destroying which I was 
obliged to make use of Jacobson's instrument twice in the month of 
January, 1833» 

It should be stated, however, that the patient was exceedingly de- 
licate and nervous, and that she would not submit to a repetition of 
the operations until a long interval had elapsed between them, and 
then for not more than two or three minutes at a time; in this way 
her cure was very considerably procrastinated. 

During the month of February Mrs. D. 's health improved very ra- 



Randolph's Cases of Lithotripsy. 19 

pidlj, and the symptoms of stone were so completely relieved that 
she was unwilling to believe she was not perfectly cured; I ascertain- 
ed, however, that there was still a fragment in the bladder, though 
of so small a size that it required some time to find it with the sound- 
The patient would not submit to any operation for the removal of this 
fragment until the £7th of this month, when I introduced Jacobson's 
instrument, and caught the fragment, and drew it out almost entire 
in the blades of the instrument; but a small portion broke off, which 
was subsequently voided during the night. From this date the symp- 
toms of stone entirely ceased; I examined the bladder very carefully 
without being able to discover the least particle of stone: Dr. Phy- 
sick also made a very minute examination, and declared himself 
quite satisfied with the cure. 

Early in March Mrs. D. returned to Virginia with her family. 

About ten months subsequently to this period Mrs. D. again came 
to this city labouring under pain and difficulty in voiding urine; con- 
siderable apprehension was expressed by several of my medical 
friends lest there should be a return of the disorder. Upon sounding 
the bladder, however, very carefully, I had the gratification to find 
that it was quite sound and entirely free from stone; the examination 
of the bladder did not cause the slightest pain, at the same time the 
nature of her complaint was rendered very apparent; she was allect- 
ed with a prolapsus uteri to a great extent. 

For the management of this latter affection she was referred to my 
excellent friend Dr. Dewees, by whose judicious treatment she was 
soon so much relieved as to be enabled to return to her home. 

Case III. Early in March, 1833, I was applied to by Mrs. M. H., 
aged twenty-eight years, who had been afflicted with the symptoms 
of stone for about three years. 

Having carefully sounded this patient, and ascertained that there 
was a stone in the bladder, of not a very large size, on the 16th of 
March I introduced the lithotripteur of M. Civiale, and having ex- 
panded the blades of the forceps I made the most careful efforts to 
catch the stone. Notwithstanding however the greatest care possible 
was used during this essay, which occupied fifteen minutes, I could 
not succeed in seizing the calculus, and accordingly was obliged to 
desist. 

The patient declared that she did not suffer the slightest incon- 
venience from these attempts. 

Having failed in catching the stone with the three-branched forceps, 
on the 20th of March I introduced the brise-pierre articule of Mr. 
Jacobson, and after a few minutes I caught the stone and broke off 



20 Randolph's Cases of Lithotripsy. 

several fragments whicli were discharged from the bladder in the 
course of the next two days. 

On the 25th of March I again introduced this instrument into the 
bladder, and caught the stone and broke it into several fragments, 
some of these were passed out with the urine, and others I took out 
from the urethra by means of my common pocket forceps. 

On the 28th inst. I again caught the stone and broke it, after which 
fragments were discharged during the days of the 29th and 30th, and 
on the 31st of March the whole remaining portion came away. From 
that moment the symptoms of stone entirely ceased, and the patient 
declared she was perfectly cured. I was quite satisfied of this being 
the fact, inasmuch as the fragments collected, when put together, 
formed an almost entire stone of oval shape, its longest diameter 
being one inch. I now however sounded the bladder very carefully, 
but could not detect any stone; a few days subsequently Dr. Physick 
also had the kindness to sound her, and declared his conviction that 
the calculus was all removed. 

It may be remarked that the treatment of this case occupied but two 
weeks, during which time the patient was not confined to her bed for a 
single hour, but continued to attend to the affairs of her house as usual. 

Case IV. The Rev. Dr. Joseph Caldwell, of Raleigh, N. C. aged 
about sixty years, arrived in this city in the latter end of April, 1833, 
labouring under the symptoms of stone in the bladder. 

Dr. C. had been afflicted with these symptoms for six years, and 
the pain attending the voiding of his urine was so great that he had 
been in the habit for a long time of drawing it off by means of a catheter. 

Having prepared this patient for the operation of lithotrity in the 
usual manner, on the 19th of May I introduced the lithotriteur into 
his bladder, without the least difficulty, in the presence of Drs. Phy- 
sick and Horner and Messrs. Kennedy, Cooke and Henn. In a 
few moments I succeeded in catching the stone, and drilled a hole 
through it; I then expanded the forceps and let the stone escape, 
and caught it again and made another perforation through it. 

The instrument was now withdrawn, and with it came away a quan- 
tity of sandy matter. The result of this operation proved that the 
calculus was a soft one, and not very large, its diameter being by 
measurement rather more than one inch. Dr. C. did not experience 
any inconvenience from this operation, which occupied twenty minutes; 
the next day he was about as well as usual. 

On the 26th of May I again introduced the lithotriteur into his 
bladder; on this occasion I caught the stone three several times, and 
made perforations through it without any difficulty. The patient did 



Randolph's Cases of Lithotripsy, 2 1 

not suffer any irritation or pain from this operation, he continued to 
be up and about his room as usual, and for several days voided along 
with his urine fine calculous matter. 

On the second of June I repeated the operation; on this occasion I 
could not succeed in drilling more than two holes through the stone- 
The instrument did not work as free in the bladder as it had done on 
the two former occasions. This operation however did not cause the 
patient any inconvenience, he was not confined at all to his bed, it 
was not followed by any fever, and he passed his urine more freely 
and also the sandy matter. 

On the sixteenth of June I again performed the operation 5 on this 
occasion I made two perforations through the stone, and by pulling 
the forceps forcibly, I succeeded in partially breaking it. No incon- 
venience followed this operation, and he passed out a larger quantity 
of fragments. 

On the S3d of June I introduced the brise-pierre articule of Mr« 
Jacobson into the bladder, soon caught the stone, and broke it 
into pieces without any difficulty. The patient did not suffer any 
pain from this operation -, on the contrary, in a few days he passed 
CHit the fragments, and experienced entire relief from the painful 
symptoms which he had formerly endured. Having examined the 
bladder several times very carefully after this operation, and not be- 
ing able to detect any stone in it, I requested Dr. Physick to make ao 
examination, which he did on the 4th of July, and after sounding ths 
bladder carefully, he expressed his belief that the patient was cured. 

On the 16th of July Dr. Caldwell left this city to return home, 
previous to which he addressed the following letter to Mr. Charles 
A. Poulson, one of the Editors of the American Daily Advertiser. 

Deab Sm, 

In reply to your inquiries respecting- my complaint, and the treatment for ita 
removal, I will briefly state, that I had been afflicted with the symptoms of 
stone in the bladder for about six years. For the last three years these symp- 
toms had occasioned me so much pain and distress, that I determined to visit 
Philadelphia, in order to seek for medical assistance, and obtain, if possible, 
relief from his terrible malady. 

I arrived in the city in the latter end of April, and immediately called upon 
Dr. Physick, who having ascertained by sounding-, that a stone was actually in 
my bladder, advised me to put myself under the care of his son-in-law, Dr. J. 
Randolph, giving me the assurance that Dr. Randolph had succeeded in several 
instances in effecting a perfect cure of this complaint by removing the stone, by 
means of the operation called "lithotrity," in which case the knife is not at all 
used. This operation, I am told, is now most successfully and almost univer- 
sally employed in Paris. I cheerfully acquiesced in this advice of Dr. Physick, 
a name I must think no less illustrious for benevolence, than for eminence in 
medical science and practical skill. Dr. Randolph took charg^e of my case, and 



22 Randolph's Cases of Lithotripsy, 

having" properly prepared me for the operation, he commenced it on the 19th 
of May, in the presence of Drs. Physick and Horner, Messrs. Kennedy, Cook, 
and Henn. The pain which I endured from the operation was not severe, nor 
did either of the necessary repetitions of it occasion me so much inconvenience 
as to oblige me to keep my bed for more than a few hours. On the 23d of June 
Dr. Randolph performed the last operation, which occupied but a few minutes. 
A few days from this time I found myself free from the pain which I had pre- 
viously suffered. The Dr. now examined me very carefully, and declared his 
conviction that I was entirely rid of the stone, and I had the heartfelt gratifies 
tion of having" this declaration confirmed by Dr. Physick, who, after a minute 
examination on the 4th of July, stated his behef that I was completely cured. 

I am yours, very respectfully, 

JOS. CALDWELL. 
Fhiladelphia, July 10th, 1833. 

It was with sincere regret I heard a few days since, indirectly, 
Hiat the Rev. Dr. Caldwell was again labouring under some painful 
symptoms of affection of the bladder; I cannot of course say what 
tlie precise nature of his complaint may be; should it however prove 
to be stone, I feel quite convinced that one or two applications of the 
hrise-pierre would be sufficient to destroy it. 

Case Y. Mr. F. G. a highly respectable merchant of this city, 
aged sixty-four years, had experienced for a period of near thirty 
years, considerable uneasiness in the urinary organs; within the last 
four years the painful symptoms were aggravated to such an extent, 
tliat in June, 1833, he was induced to consult Dr. Physick, who, 
upon sounding him, ascertained the existence of a stone in the blad- 
der, and had the kindness to place him under my charge. 

Upon examination I discovered that his urethra was unusually small;, 
tlie bladder also was very much contracted and irritable; he seldom 
was able to void at one time more than a large wine-glassful of urinow 

I attempted to inject barley water into his bladder, but could not 
succeed in introducing more than four ounces of the fluid, and this 
caused him so much pain that I did not resort to it again. 

On the 12th of June I introduced the lithotripteur. No. 4, in the 
presence of Dr. Physick and G. W. Ritter, Messrs. Kennedy, Cooke 
and Henn. I very soon succeeded in catching the stone, and drilling 
a hole through it; I then changed its position, and made another per- 
foration through it. I soon perceived that the instrument used 
upon this occasion was rather larger than it should have been; 
it did not work readily in the bladder, and it required some force |;o 
withdraw it, in consequence of the blades of the forceps enclosing 
some sand and mucus which prevented their closing entirely. Subse- 
quently to the operation, Mr. G. voided with the urine a good deal 
of fine, red, sandy matter; the stone was found to be composed of 
uric acid, and its diameter was about one inch and a half. 



Randolph's Cases of Lithotripsy. 2B 

Some hours after the operation the patient was attacked with a 
diill, which was followed by some feverj this, however, yielded to a 
bleeding and saline diaphoretics. 

On the 5th of July I introduced the lithotripteur, No. 3^ very 
readily caught the stone, and made several perforations through it, 
and perceived it to break away considerably. This instrument was 
introduced and withdrawn without appearing to cause him any pain or 
irritation; he remained setting up the whole of this day, and felt welL 
On the day following the operation, however, he had a fever, which 
continued for some time; for the relief of which it was necessary to 
bleed him twice, and apply leeches over the pubes. 

Knowing the stone to be much reduced in size by these two opera- 
tions, and taking into consideration the extreme irritability of the 
bladder, I determined not to make any further attempts to destroy 
the stone until the heat of the summer had passed away, and then to 
make use of the instrument of Mr. Jacobson in preference to that of 
M. Civiale. In accordance with the foregoing resolution, as soon as 
the weather became cool I made five or six applications of the brise- 
pierre, (I have not kept a record of the dates,) and succeeded com- 
pletely in breaking up the stone. Neither of these operations occu- 
pied more than two or three minutes; the last one was performed in 
November; a short time subsequently to which, Mr. G. passed out 
the whole of the remaining fragments, and declared himself to be 
perfectly free from all the painful symptoms he had formerly endured. 
I now sounded him very carefully, but could not detect any stone. 
Soon after the operation Mr. G.'s urine increased in quantity very 
much, and he can now retain it for five or six hours. 

It will be perceived that Mr. G.'s case occupied a considerable 
time: I will just remark, that his case was an exceedingly difficult 
one; his situation was very critical; my object was to cure him in the 
safest manner possible; his condition was fortunately such as to al- 
low me ample time, and I accordingly proceeded very cautiously 
and am happy that my eSbrts were crowned with complete success. 

Case VI. Richard Judson, aged sixty-five years, a native of En- 
gland, had been afiiicted with the symptoms of stone for several years, 
he arrived in this city in September, 1833, and applied to me for advice. 
Upon sounding this patient I ascertained clearly the existence of 
stone in the bladder; the urethra was uncommonly large, but I found 
it utterly impossible to introduce a straight sound into his bladder; 
the instrument would pass readily as far as the neck of the bladder, 
and there it stopped; I at once inferred that the obstacle was occasion- 
ed either by an enlargement of the third lobe of the prostate gland, 
or by a tumour situated at the neck of the bladder. 



J&4 Randolph's Cases of Lithotripsy. 

In addition to the symptoms of stone, which were exceedingly 
painful, Mr. J. was also affected with a most obstinate costive- 
ness, he rarely had a passage under six or seven days, and 
tlien not without the aid of an aperient; the hardened portion of 
the feces came away diminished in size, so as to resemble a large 
worm; there was also a discharge of mucus from the rectum some- 
times mixed with blood. 

I must confess that I did not pay a great deal of attention to these 
symptoms, thinking they might be occasioned either by a stricture of 
tlie rectum or by hsemorrhoids, and considering the stone to be the 
most prominent disorder, to the removal of which last I directed my 
first efforts. 

As I could not succeed in getting a straight instrument into the 
bladder, I was obliged to abandon of course all idea of employing the 
lithotripteur. On the 4th of October I introduced Jacobson's instru- 
ment, and caught the stone and broke it readily several times. I 
then withdrew the instrument which brought out within its blades a 
quantity of calculous matter; the patient suffered very little pain from 
tliis operation, and it was not followed by a single unpleasant symp- 
tom; he continued for many days to pass out sand and fragments, 
together with one or two distinct small stones. From this period I 
did not keep a record of the number or dates of the operations, I 
requested the patient to note them down, and he promised to do so, 
but neglected it. 

The second operation was performed about the latter end of this 
month; on this occasion I caught the stone without difficulty and 
crushed it several times; I also perceived that the instrument had 
caught hold of some soft substance, upon withdrawing it I was aston- 
ished to find that along with calculous matter I had extracted a por- 
tion of a firm, fleshy tumour. 

I freely acknowledge that I felt considerable anxiety respecting the 
result of this operation; I kept the patient in bed for several days, 
and watched him very closely; to my agreeable surprise however it 
was not followed by the slightest fever or any other bad symptom; 
on the contrary he rested better at night, and felt himself more re- 
lieved from pain. After this operation the patient discharged a con- 
siderable number of fragments, together with seven or eight distinct 
stones of large size, of some of which the shortest diameter was by 
actual measurement half an inch. 

Between this period and the beginning of June, 1834, I made pro- 
bably ten or twelve applications of the brise-pierre; neither of the ope- 
rations however occupied more than two or three minutes, nor were 
any of them followed by unpleasant symptoms; the quantity of stone 



Randolph's Cases of Lithotripsy. 25 

voided after these operatioRS was immense, the bladder in fact ap- 
peared to be almost completely filled with calculous matter. It 
should be stated that during the winter the patient's system got into 
a prostrated state, unconnected with any aggravation of the calculous 
symptoms, in consequence of which however 1 did not think it proper 
to apply the instrument for near tv/o months. 

The last operation was performed in the beginning of June, it oc- 
cupied two minutes; one hour after its performance the patient was 
up and about his room as usual. A short time subsequently to this 
operation I sounded the bladder very carefully, and could not detect 
any stone; expressed the opinion that it was sufficiently broken up; 
and stating that there might be some small fragments remaining, but 
that I thought they would be discharged without my being obliged to 
employ again the brise-pierre. 

In the beginning of July Mr. Judson was looking out for a situa- 
tion in the country, to which he could retire during the warm weather, 
which seemed to distress him exceedingly; a,bout the 20th of the month 
however he was attacked with a diarrhoea, and he died on the 29th. 

On the 30th my friend Dr. Pancoast had the kindness to make 
for me the post mortem examination; upon taking out the bladder and 
rectum I had the gratification to find that I had succeeded most com- 
pletely in breaking up the whole of the stones; there were remaining 
in the bladder but four small fragments, much smaller than a great 
many others which he had passed through the urethra, and had he lived 
a short time longer these would unquestionably have been discharged. 

The structure of the bladder itself did not exhibit the slightest 
evidence of having been in the least degree injured by my operations; 
the following note however which I received from Dr. Pancoast will 
best explain the morbid condition of this organ, and of the rectum, to- 
gether with the probable cause of the patient's death. 

Dear Sir, 

In compliance with your request I have made an autopsic exarahiatlon of 
Hichard Judson. From the nature of the case, and the shortness of the time al- 
lowed me, I limited my attention more particularly to the study of the abdo- 
minal and pelvic viscera. 

The peritoneum, both in the pelvis and abdomen, was perfectly healthy. 
The mucous membrane of the intestines was more vascular and of a darker co- 
lour than usual. Many patches of a dark-brown colour were found at the lower 
extremity of the ileon. The follicles were also very much enlarged, especially 
in the large intestines. 

Both kidneys were found of their usual size; containing' no calculi. When 
laid open they appeared much softer than usual, so that the finger could be 
readily passed through them. They were of a purplish hue; the cellular and adi- 
pose tissue surrounding them were hard and dense, and could be separated 

No. XXIX.— November, 1834. 3 



26 Randolph's Cases of Lithotripsy. 

from the kidney without tearing- up its cortical substance. This, with the hy- 
peremia and softening-, constitute the strongest anatomical characteristic of long 
existing nephritis. The pelvis and ureters were healthy in appearance, though 
enlarged to about four times their natural size. The bladder was much con- 
tracted; the walls thickened to about twice their natural dimensions, and of 
greater density than usual. The cellular tissue connecting it with the rectum 
and prostate gland, was so hard and dense as to seem to have prevented even 
a moderate dilatation of the bladder; thus probably causing the dilatation of the 
ducts of the kidneys by the accumulation of urine in them. From the healthi- 
ness of the structure of these ducts, the inflammation of the kidneys could not 
within any recent time, at least, have been an extension of disease from the 
bladder. The mucous membrane of the bladder was thicker, but not softer than 
usual. The cavity of the bladder was of very irregular form; the prostate was 
enormously enlarged, and generally of a scirrhous hardness; it formed an irre- 
gular sphere of about two inches and a half in diameter; its vertical develop- 
ment was almost entirely at the expense of the cavity of the bladder. The pro- 
jection made by the middle lobe into the bladder was about the usual size of 
the entire gland. On each of the enlarged lateral lobes was a projection over- 
hanging the caput gallinaglnis, about the size of the human ovary. The open- 
ing into the bladder was thus very much obstructed, and nearly vertical at the 
prostate gland owing to the projection of the middle lobe. On the right side of 
the caput gallinaginis, was found one and on the left two smooth, oval cavities, 
extending almost to the bottom of the prostate, all of which appeared to have 
contained calculi, and in one a small calculus was found. These cavities were 
from half an inch to three-quarters in diameter. The bas fond of the bladder 
was formed of two similar cavities, with an elevation of the mucous membrane 
between them. In the posterior wall several cavities of the same sort were 
found, two of which contained small stones. The cysts were formed of all the 
tunics of the bladder. Four fragments of calculi were found free; the largest of 
which was about the size of a small hazelnut. The projections of the prostate 
gland into the bladder, were softened and pultaceous at their top, and of a 
dark colour. In the centre, and on the side of the rectum, the gland was of a 
scirrhous hardness, and of a bluish colour. 

The anterior wall of the rectum, immediately adjoining the prostate, was 
softened and almost removed by ulceration, for an extent about equal to the 
size of the gland. The margin of the ulcer was steep and scirrhous; the tunics 
of the intestines blended together by the disease, with that complete loss of 
anatomical character which we observe in cancer. Opposite this place, and 
just below it, the calibre of the intestine was very much contracted, so as to 
leave but a very narrow opening for the passage of the faeces. 

Yours, very truly, ' 

To Dr. Randolph. J. PANCOAST. 

As I propose at some future day, upon greater experience, to of- 
fer my vievi^s relative to this most interesting operation, more at large, 
to the profession, I shall not at present anticipate any remarks which 
I may then have to make, further than by replying to one or two ob- 
jections which have been urged against the operation. 



Randolph's Cases of Lithotripsy. 27 

It has been stated, and that too by some who profess themselves 
friendly to lithotripsy, that this operation will be found applicable to 
a small minority only of the cases of stone. The ample experience of 
the European gentlemen engaged in the performance of this opera- 
tion, backed also by my own limited observations, has led me to a 
very different conclusion. I believe that of the cases of stone in 
adults, eight out of ten will be found suitable to the operation of li- 
thotripsy. Stone occurring among children I do not take into con- 
sideration, because in them the operation of lithotomy is compa- 
ratively so safe that I do not think it requires a substitute. 

Since engaging in my first case of lithotripsy, in September, 1832, 
ten cases of stone in adults have come under my noticej the history 
of six of these cases I have already detailed. The seventh case pc- 
curred in a coloured female, who had a small stone, which I have no 
doubt could readily have been crushed; she, however, suddenly dis- 
appeared, and 1 have never seen her since. The eighth case occurred 
in a young man from Virginia, upon whom I operated twice success- 
fully in the Alms-house Infirmary, in the presence of a number of 
gentlemen; this patient unfortunately contracted a typhus fever, and 
when convalescent, returned home to recruit his strength, under a 
promise to return; he, however, was induced to submit to lithotomy 
in Virginia, and it was stated that the stone was broken by my opera- 
tions. The ninth case occurred in a gentleman of this city, who 
changed his mind during the preparatory steps for lithotripsy, and 
was successfully cut by Dr. Harris. Dr. H. informed me subse- 
quently, that the stone was so soft that it broke into pieces in ex- 
tracting it from the bladder. 

The tenth case occurred in a medical gentleman who came on to 
this city from North Carolina, with the express view of submitting 
to the operation of lithotripsy; I freely admit that the operation was 
not applicable to this case; upon repeated examination I ascertained 
that there was an ulcer situated just beyond the mouth of the urethra, 
in consequence of which the canal was so much contracted at that 
part, and the attempts to dilate were productive of so much pain, 
that I was obliged to abandon lithotripsy, and perform on him the 
operation of lithotomy, which terminated successfully. 

Another principal objection which has been urged against the ope- 
ration of lithotripsy, consists in the difficulty of extracting the numer- 
ous fragments into which the stone may be broken, and the liability 
of such fragments to remain in the bladder and serve as nuclei for 
the formation of other stones. This may appear to be a very important 
consideration to persons unacquainted with the extraordinary power 
which the bladder and urethra possess to discharge foreign substances 



23 Randolph's Cases of Lithotripsy, 

lodged in them. I have so repeatedly, however, witnessed the dis- 
charge of fragments, of almost incredible size, that I am well con- 
vinced this difficulty has been very much exaggerated, and I believe 
that by proper attention, any fragment which may exist in the blad- 
der, and be too large to pass into the urethra, can be detected by a 
sound, and broken up by an instrument, so as to admit of being dis- 
charged. 

With respect to the fragments lodging in the bladder, and serving 
as nuclei for other stones, I here wish to record a fact, which I am not 
aware has been noticed by any preceding writer, it is this — ihsii frag- 
ments of stone lodged in the bladder^ and too large to pass through the 
urethra, so far from invariably increasing in size by accretion, in 
Qnany instances have their angles and sharp corners so rounded off by 
the action of the urine, as to be reduced to a less size, and admit of 
being discharged. I have several specimens which conclusively illus- 
trate this fact. 

If it be admitted, however, that a fragment of stone remaining in the 
bladder forms a sufficient objection to the operation of lithotripsy, it 
must be conceded that the same objection applies in no small degree to 
the operation of lithotomy. It not unfrequently happens in extracting 
a stone through an incision of the bladder, that owing to its softness 
it is crushed into innumerable fragments by the blades of the forceps, 
and under such circumstances, no man, whatever care he may exer- 
cise, can say with certainty that he has extracted every particle of the 
calculus. I believe the operation of lithotomy is very rarely perform- 
ed without some small fragment of stone being broken off during its 
extraction, in a great majority of cases such a fragment escapes from 
the bladder along with the urine; in other instances, however, it may 
remain and serve as a nucleus for another stone. Cases indeed are 
reported in which after the operation of lithotomy has been perform- 
ed, there has been a recurrence of the stone, and the patients have 
been cured by the operation of lithotripsy. 

With respect to the comparative safety of the operations of litho- 
tripsy and lithotomy, this is a point which experience alone can de- 
termine; my own impressions are in favour of the former operation, 
at any rate it is the one which I would select to have performed on 
myself in case of need. 

It must be conceded that the operation of lithotripsy possesses one 
great advantage over lithotomy, sufficient, I think, of itself to out- 
weigh all the objections which have been enumerated — which is, that 
it is not attended with the danger of incontinence of urine. 

This evil which not unfrequently occurs in males, and almost in- 
variably ensues from the operation of lithotomy in females, is itself 



Randolph's Cases of Lithotripsy. 29 

of such magnitude as to render life scarcely desirable. May we not 
hope that the day has arrived when no man will be willing to sub- 
ject an unfortunate female to such a terrible consequence, by re- 
sorting to the operation of lithotomy instead of lithotripsy. 

I do not propose to enter upon a discussion of the relative merits 
of the several instruments used for the performance of this operation; 
it is very natural that the inventor of each of these should endeavour 
to establish his own method, by using every argument in his power 
in favour of his own instrument, and saying as little as possible in 
praise of that of his rival. 

Admitting that M. Civiale has exaggerated not a little the success- 
ful results of his operations, still it cannot be questioned that he has 
performed a sufficient number of cures to immortalize his name, and 
we cannot for a moment suppose that the rewards and honours which 
have been heaped upon him by competent judges, would have been 
bestowed upon one undeserving of them. 

Mr. Leroy d'Etiolle, who claims the merit of being the princi- 
pal author of the operation of lithotrity, in a statement made by him 
in July, 1833, says, that out of thirteen cases of stone he succeeded 
in curing twelve; he admits, however, that in each of these opera- 
tions he made use of the brise-pierre articule of Mr. Jacobson, and 
that three of the cases were cured by means of this instrument alone. 

The "percuteur courbe a marteau," invented by Baron Heur- 
TELOUP, I have not yet had an opportunity of procuring; the success 
derived from its application by its distinguished author has been flat- 
tering in the extreme; out of thirty-eight cases of stone he succeeded 
in curing thirty seven; these operations were witnessed, and are cer- 
tified to by some of the most distinguished surgeons and physicians 
of all Europe. 

Sir AsTLEY Cooper placed the unsuccessful case under the care 
of the Baron, and after death furnished its autopsic history, in which 
he says there were sufficient causes of death independent of the ope- 
ration. 

It is not necessary for me to repeat what I have already said in 
praise of Mr. Jacobson's instrument. 

I cannot conclude this paper without offering to each of the names 
I have enumerated the homage of my unfeigned admiration and re- 
spect for having ameliorated the condition of suffering humanity, and 
enriched our science by the introduction of their most useful and im- 
portant discoveries. 

Philadelphia^ September 1st, 1834. 

3* 



30 Barton on Epidemic Yellow Fever. 



Art. II. Account of the Epidemic Yellow Fever which prevailed in 
New Orleans during the Autumn (/ISSS. Bj Edward H. Bar- 
ton, M. D. 

New ORLEANS is situated in latitude 29° 57', and longitude 
west from Washington 13° 9', on the left bank, and in a large 
bend of the Mississippi. It is ten feet and a half above the level of 
the sea, from which it is distant in the course of the river about one 
hundred miles, about sixty miles in a south west, and about forty in 
an eastward course. Five miles north of it is Lake Ponchartrain, 
which receives the drainage of the city and superfluous waters of the 
vicinity through the Bayou, St. John, &c. The inclination from 
Levee street in front, to Rue Marais in the rear, is about eight feet 
three inches. The city is fanned by the delightful sea breeze from 
the south west every morning, which is the harbinger of health whilst 
the prevalent wind. The river rises about fourteen feet, and gene- 
rally reaches its maximum elevation late in March or early in April. 
The level of the city is several feet below high water mark, and it 
is protected from inundation by an embankment or levee three feet 
and a half high, which extends about five miles along the river, and 
about two-thirds of a mile back to the swamp. The city is built 
upon a soft alluvial soil but a few feet above the water in the 
wells, (dependent upon the state of the river,) the dampness is 
consequently very great: the streets are filthy, and but partially and 
badly paved. In the body of the city, (gV^'^ ^f ^'^^ whole area,) water 
is made to run constantly along the gutters from the river to the 
swamps during the summer* In 1830 the city contained about 
46,310 inhabitants, exclusive of a floating population during the 
winter and spring months of from 15 to 20,000j increasing on an 
average of near 2^ per cent, per annum, and hence containing in 
1833, 53,234, making altogether about 70,000 inhabitants. 

The prevailing diseases of January, February, March, and April, 
1833, were decidedly intestinal — diarrhoea, dysentery, and many 
cases of cholera. 

During May the range of the thermometer was 18°; maximum be- 
ing 88; minimum 70, and average of the whole month 78.42. The 
range of the barometer was .30, the maximum 29.70, minimum 29.40, 
and average 29.74. Winds principally from the S. W.; quantity of 
rain 6.22 inches. The character of the diseases continued to be de- 
cidedly intestinal, with a great tendency to run into cholera from ne- 
glect or improper treatment. 



Barton on Epidemic Yellow Fever. 31 

In June the range of temperature was 25°; the highest being 94; 
lowest 69; average 82.09. Barometric range .43; the maximum being 
29.75; minimum 29.32; average 29.62. Rain 6.22 inches. Winds 
steadily from S. E.; in latter part of the month more S. W.; weather 
raw, disagreeable, and particularly so when the cholera reached its 
height, about the 8th, when there occurred a heavy fall of rain, with 
much thunder and lightning, soon after which the wind veered round 
to the S. W. and W. the disease gradually declined. The epidemic 
strongly impressed its character upon most diseases of the month, 
uniting its symptoms with those of other diseases, as cramps, or rice 
water discharges, with ordinary symptoms of bilious fever — or the 
peculiar coldness, or the vomiting, with a great and indeed excessive 
sensibility of the alimentary canal, with liability to run into diarrhoea 
upon the least change of temperature or transgression in living. This 
disease was indiscriminate in its attaciis, with regard to age, sex, or 
colour, selecting those whose equilibrium of constitution was de- 
ranged or thrown from its balance from intemperance or imprudence 
of any kind, or from change of diet — always however with premoni- 
tory diarrhoea, ranging in its duration from six to forty-eight hour?, 
and running into collapse in from three to twenty hours. The disease 
finally lost its intensity and prevalence with the changes in the con- 
dition of the atmosphere. 

The thermometric range in July was 19°; highest 90; lowest 71 j 
average 81.13. Barometric range .25; maximum, 29.82; minimum 
29.57^ average 29.70. The prevailing winds were S. E. and S. W« 
Weather showery; the fall of rain but 3.3 inches: the city again be- 
came pretty healthy, though great liability to take on intestinal dis- 
ease on change of weather to cold and damp, and with east windsj 
and during the highest range with cold nights, bilious fever. 

During August the range of the thermometer was 19; the highest 
being 90; lowest 71; average 79.97. The barometric range .27; the 
maximum 29.79; minimum 29.52; average 29.58. Rain 8.17 inches. 
The winds in early part of the month mostly S. W. and N. W. — a 
few days from S. E. The weather showery; days and nights hot and 
oppressive; the thermometer often at 10 and 12 P. M. and at 1 A. M. 
as high as 81, 2, 3, and 4! a height of temperature, at night, unpre- 
cedented in this country, where the summer nights are usually as cool 
and pleasant as in any part of America. Before the middle of the 
month the wind got round to the eastward, and continued blowing 
fresh with a high thermometric range, the weather very oppressive 
and showery, and from the streets there arose a very offensive odour. 
In the second week the yellow fever broke out, and continued in-- 



22 Barton on Epidemic Yellow Fever. 

creasing until it reached a daily average of thirty cases. Its type was 
mostly malignant, with great determination to the head. 

During September the thermometric range was 21; the highest be- 
ing 88; lowest 67; average 77.57. The barometric range .23; the 
maximum 29.73; minimum 29.50; average 29.60. Rain 5.50 inches. 
Winds regularly E. and S. E. until 21st, when they came from the 
N. continuing three days; thence returning to S. E., E., N. E., blow- 
ing all the time very fresh. The weather being exceedingly disagree- 
able and raw — during the first week rain almost every day, and pro- 
ducing an influence on one's feelings beyond the temperature and 
moisture, there being a great deficiency in reaction in the cases; 
during the second week more hot and oppressive; temperature at 
night 79 and 81. The diseases during this week were more mild and 
manageable, though the number of cases was not diminished. Dur- 
ing the third week the weather was more pleasant, though warm for 
the season — the winds shifting, but never getting west for more than 
an hour or two; the number of cases lessening, probably from fewer 
subjects, but strangers came in, and added somewhat to the mortality. 
The disease now participating more of the type of our usual fall 
fever, with symptoms of deeply radicated gastro-enteritis, with coma- 
tose tendency. In the latter part of the month some intermittent 
fevers, diarrhoea, dysentery, and a few cases of cholera. 

During October the thermometric range was 391 — the highest being 
80; lowest 41i, and average 65.53. The barometric range .43; 
maximum, 30.03; minimum, 29.60; average, 29.75; rain, 3.5 inches. 
The weather has been during the first week very pleasant, some cold 
mornings, but middle of the day hot. Winds N. W. to N. E. and 
E. The disease became more mild, the type somewhat changed; eyes 
not red; tongue less white on surface, but edges more deeply red, 
and sooner become dry; fever continues longer, and skin more ob- 
stinately dry. Some of intermittent and remittent type; the cold 
weather found very injurious to the sick. The weather continued 
rather warm to the 18th, and then gradually cooled down on the 22d 
to 41 5, when there was perceived a slight frost in several parts of the 
city, and some ice was seen, the winds changing from S. E. and S. 
to N. W. and N. and still blowing fresh. There has been no calm 
throughout the season. The disease continued notwithstanding se- 
veral frosts, though mostly confined to new-comers, and particularly 
steerage passengers. The wind in the latter part of the month occa- 
sionally from its old quarter, S. E. and E. and N. E. and high; dust 
very oppressive from the long drought. The type of the disease con- 
tinued to change from the ardent character of the first part of the 



Barton on Epidemic Yellow Fever. 33 

season; no great external heat and with a particular disposition to run 
into a protracted form; not the same force and activity of the sympa- 
thies; there did not seem such an urgent demand for activity of treat- 
ment. Disease mostly confined to steerage passengers and strangers 
generally. 

The thermometer's range during November vi^as 50 — the highest 77; 
lowest 27, average for the month 55.03. The barometric range .53; 
maximum 29.97; minimum 29.44; average 29.73; rain 2.40 inches. 
The winds in early part of the month S. E. and E. temperature, very 
pleasant. It changed about the 10th or 12th, the day preceding the 
splendid meteoric phenomenon of the falling and shooting stars, 
to N. and N. W. and seldom was E. again. The disease gra- 
dually disappeared — during the first week some cases at first 
wanted none of the symptoms of the epidemic, notwithstanding 
the frosts which were unusually early and severe; and in the 
latter part of the month much of bronchial irritation developed itself. 

J) wv'm^ December the thermometer's range was 44, the highest being 
72, lowest 28, average 56.65. Barometric range .53; maximum 
29.93; minimum 29.40; average 29.68; rain 3.71 inches; the winds 
very variable, N. E., N. W., S. W., &c. It has been an unusually 
cold month, rains frequent, and hail the size of a musket ball on the 
13th. Bronchial irritations and inflammations the prevalent disease^ 
with a few cases of scarlatina and cholera. 

As precursory to the dreadful scourge which followed, it becomes me 
to mention several enlargements of the inguinal glands, occurring 
without the least suspicion of venereal contamination, similar to those 
mentioned by authors as premonitory of the existence of mortal epi- 
demics; also several cases of menorrhagia. The streets throughout the 
city were filthy, exhaled a peculiarly offensive odour after rains, and 
generally so at night. There was much sickness with horses, cattle, 
and swine in the country. 

The country throughout was unusually sickly; crops fine; fruit bad. 
Weather during autumn beautiful, air cool, delightful atmosphere, 
exhibiting the brightness of an Italian sky, as has been so often re- 
marked during our severe epidemics. 

DiEMERBROECK, (on the authority of a number of writers; and the 
same has been remarked by Dr. Rush and many others,) observes 
that an uncommon abundance of insects, for many years has been 
noticed to portend pestilence, and we accordingly remarked here, 
that the flies and mosquitoes particularly were unusually numerous 
preceding the epidemic—the latter continued throughout the season. 



34 Barton on Epidemic Yellow Fever. 

From the preceding succinct and general medical and meteorolo- 
gical history of the year, it cannot have escaped attention that the 
precursors of the malignant epidemic of the season were gastro-intes- 
tinal affections of every grade and severity, from simple extra-sensi- 
bility of the gastro-intestinal mucous membrane, to the malignant cho- 
lera running its course in six hours. The evils resulting from this epi- 
demic constitution of the atmosphere, and the predisposition to the 
malignant yellow^ fever that afterwards occurred, was greatly aggra- 
vated by the adoption of the advice so generally given, to live high 
and drink freely of brandy, &c. to prevent an attack of cholera. 

The local causes of the epidemic are numerous, some of them 
so nearly aff*ecting the habits and prejudices of the people, that they 
have been pointed out in vain, and I therefore forbear extending the 
limits of this paper by enumerating them. 

The heat of the nights in early summer was a departure from our 
general experience in this climate, and the long continuance of the 
easterly winds, blowing fresh at the time, (not one day, and 
scarcely an hour calm,) with their remarkable influence, as everyone 
observed, in lowering the healthy tone of the body, probably from de- 
priving it of its electricity, doubtless influenced to a great extent the 
intensity of the prevailing disease. These winds uniformly exasperat- 
ed the yellow fever, and if they do so, they can surely tend to pro- 
duce it. The truth is, that during the great epidemics of 1800 and 
1819, these winds ^<' prevailed constantly for a period of three months, ^^ 
The same occurred here in both the epidemics of 1833, (cho- 
lera and yellow fever,) during the dengue in 1828, and also precur- 
sory to and at that time, to an unprecedented extent preceding and 
during the dreadful epidemic cholera here of November, 1832, and the 
injuriouseff*ectof easterly winds has been remarked by others.* The un- 
usually early and severe fall and winter will long be remembered^ in- 
deed since the epidemic cholera reached America, and some years be- 
fore, there had been a series of wnse«sona&Ze years, defying all the calcu- 
lations and anticipations of the planter — destroying his hopes and 
blasting his fortunes, only paralleled by the character of the same 
dark drama of floods and failures of crops which has been enacted on 
a more costly scale to the Asiatic nations, preceding and coexisting 
with the outbreak of epidemic cholera there in 1817; such as droughts 
and deluges, storms and tempests, and a range of temperature out of 
all season and experience. These remarks have been verified byre- 

• Vide Chapman on Epidemics, and Edinburgh Review, No. 72, &c. 



Barton on Epidemic Yellow Fever, 35 

ference to my meteorological journal, which I have kept for nearly 
fifteen years. 

To the medical historian of this yearns remarkable incidents belongs 
the curious fact, which has been elsewhere observed, of an increased 
tendency in females to multiply during and after great general epi- 
demics, after a cessation of many years, as if it were in the order of 
Providence to supply the place of those taken off by the ravages of 
pestilence. Numerous instances have fallen under the knowledge 
of myself and friends, too many for remarkable coincidences; one 
■where the lady had ceased twenty -jive years, being fifty years of age^ 
another thirteen, &c. &c. It is in vain to speculate upon an occur- 
rence so extraordinary; our life, death and existence in every varia- 
tion and gradation are dependant upon the condition of the atmos- 
phere in which "we live, move and have our being," how important 
then to study its character, to understand and modify its influence, 
and prevent and cure the diseases incident to its qualities and vicis- 
situdes. 

The range of the thermometer has been supposed to have great in- 
fluence in the production of yellow fever, and meteorological tables 
from 1793 to 1817 in Philadelphia, embracing numerous epidemic 
years, have been published, showing its connexion, if not dependance 
upon it, and a successful attempt seems to have been made to demon- 
strate its dependance upon an average at 3 o'clock of not less than 
79° during the summer, and especially during the two whole months 
of June and July; and the extent and malignancy of the disease to be 
proportioned to the extent in which it exceeds that height; and the 
writer successfully refers, as proofs, to the tables of mortality occur- 
ring during the above period of twenty-five years; and he further be- 
lieves, that the average temperature of the two months of June and 
July, at 3 P. M. (or midday,) to govern the season, with reference 
to health, insomuch that if by the 1st of August in any year the ther- 
mometer properly placed, indicate during these periods a less degree 
than 79°, we may feel full confidence that during that season they 
will not there be afflicted with yellow fever. We are not without 
other authorities bearing upon the same point. Sir Gilbert Blane 
says that "this fever is restricted to a certain range of atmospheric 
temperature, not appearing unless the heat of the air is permanently 
equal to that within the tropics, that is, about 80°;" and M. Are- 
juLA, (a Spanish physician of eminence,) says "that under 23° 
Reaumur, (82° Fahrenheit,) it never appears." Let us see how far 
this will apply to our climate for the last season — its bearing or con- 
nexion with former years, I reserve for a future opportunity. 



36 Barton on Epidemic Yellow Fever» 



1833. 


Midday. 


Average 


; for the Month, 


June - - . 


86.76 


. 


82.09 


July - 


85.16 


. 


81.13 


August 


83.61 


. 


79.97 


September 


83. 


. 


77,57 



This appears to afford a strong corroboration of the authority above 
cited. 

The epidemic, of which it is the especial object of this paper to give 
an account, commenced its ravages on the first week of August, reach- 
ed its acme about the middle of November, and gradually lost its pecu- 
liar character in the first week of November. 

As it is impossible to embrace in one general view a fever whose 
various types were easily recognised by the eye of experience and 
observation, I shall notice such grades as were obvious to me. These 
varieties do not indicate any specific difference of action, but consti- 
tute different grades of the same action, in individuals of different 
temperaments, susceptibilities, exposures; form natural classes, hav- 
ing a family likeness, which are essential to be observed, as leading 
to a just prognosis and proper treatment. 

Class I. The Congestive. — The attack is sudden, the patient is at 
once prostrated and overwhelmed; there is dull pain in head; ques- 
tions are answered with difficulty; skin bronzed; eyes red and muddy, 
like one drunk; pulse weak, soft, or natural; tongue with red edges 
or natural; extremities cold, and skin generally so, except the central 
portions of the body, which are preternaturally h^t; pain and oppres- 
sion in epigastrium; appearance of great anguish, or insensibility; the 
patient lying uncomplaining on one side or back as if but little ailed 
him; stupor; pupils enlarged; haemorrhages. Reaction slow, and re- 
quiring much but cautious depletion to open the condition. See Case 
II. as a prototype of this class. 

Class II. The open inflammatory form. — This was the most usual, 
it commenced generally with a chilliness, followed by violent pain in 
the lower part of the forehead, just below the eyebrows, and in the 
back and loins; high fever; pulse from 100 to 125; tongue white with 
red edges; eyes inflamed and blood-shot, with the peculiar muddy, 
idiotic expression, with great sensibility of the stomach, and ardent 
desire for cool drinks; tenderness and tension in epigastrium, running 
through regular stages. See Cases I., III. &c. 

Class III. Simple Form. — This class differs but little from the 
preceding, except in the general mildness of the symptoms; the pain 
in the head is more diffused and general ; not much or severe pain in back 
or extremities; the tongue sometimes loaded, edges red and fleshy, 



Barton on Epidemic Yellow Fever. 37 

atitl still great sensibility of the alimentary canal to medicines; the 
type easily recognised by the peculiar expression of the eyes, not so 
red and injected, but dull and muddy, occurring mostly in the latter 
part of the season, or in those accustomed to a southern latitude, in 
whom the predisposition was not strong, and acclimating mild. 

The common course of the fever is to commence, often without 
any preceding indisposition or premonitory warning, with a chill 
which lasts sometimes half an hour, usually less, though sometimes it is 
absent. This chill is followed by high fever, with an intense super-or- 
bitarpain, apparently unconnected with great disordered action of the 
brain, as the intellectual functions are generally unimpaired, though 
occasionally there is delirium — a peculiar inflamed glossy appear- 
ance of the eye, easily recognised but difficult to describe, a strange 
compound of muddiness and lustre; pulse 120; great thirst, and de- 
sire for cold drinks, with occasional vomiting; pain and heat of sto- 
mach; tongue white on surface, with red edges; this generally conti- 
nues with more or less intensity from twenty-four to forty-eight hours, 
when there is a remission of all the symptoms, and the patient often 
feels very well. There is often an anxious expression of the counte- 
nance, and jactitation. This condition continues from twelve to 
twenty-four hours — depending very much upon the treatment; if re- 
cur, fever returns, with vomiting or delirium; pain in the head; often 
suppression of urine; haemorrhages; extreme sensibility of stomach; 
black vomit; death. 

In internal diseases we cannot see the organs which suffer, but for- 
tunately for humanity, suffering organs speak a language through the 
sympathies, (the symptoms,) which should never be misunderstood. 
For the deficiency of our senses we call upon the resources of our rea- 
soning faculties; for it will be admitted that many things are demon- 
strable to reason that are not so to sense, and if we cannot see the 
diseased organ, we will interpret the language which nature speaks, 
and direct our treatment, (the only purpose in understanding it^) to 
answer her petitions for relief. 

Appended to this article will be found a condensed abstract from 
a detailed table, (too large for publication,) kept of all the cases oc- 
curring under our immediate care during the epidemic, and an account 
of the symptoms of the disease, so far as they could be procured, 
showing the participations in the disease of the great organic appara- 
tuses of the system. From this table it will appear, (and the analysis 
is necessarily very imperfect;) 1st, that in every case of yellow 
fever the stomach is more or less inflamed — that it is the pri- 
mary seat of disordered action, from which emanate directly or indi- 
No. XXIX.— November, 1834. 



38 Barton on Epidemic Yellow Fever. 

rectlj all the symptoms; that the other organs are variably and sym- 
pathetically affected; that they can be removed without removing 
the disease; that this relief is by means acting through the stomachy 
that when the symptoms of affection of the stomach are removed, 
the disease is cotemporaneously removed; that the direct effect of 
treatment, whether stimulant or antiphlogistic, shows its direct in- 
fluence on the disease through the stomach — in the first case, aggra- 
vating the symptoms — in the second, relieving them: and finally, 
the appearances after death, showing the causa mortis to be gastro- 
duodenitis. To the all-important question, then, what organ suffers most 
and primarily in yellow fever, the disorganization of which produces 
death, the restoration of which produces health, and which is the seat of 
the ravages found after death, will be answered by an analysis of the 
symptoms, and by reference of them to their true and only origin — the 
stomach. This organ is connected to other organs by two order of sym- 
pathies : 1 st, the organic sympathies; and 2d, sympathies of relation. To 
the first belong affections of the hearty as great frequency, or great slow- 
ness of the pulse. One case occurred in which the pulse was but 40 in 
the minute during nearly three days; the intense beef-steak redness of 
the tongue; anxious expression of countenance; pain on pressure in epi- 
gastrium, and on drinking warm or stimulating fluids, and the great 
desire for, and gratification on, drinking cool and subacid fluids, left 
no doubt of the correctness of attributing it to inflamed stomach — 
which was proved also by two local bleedings from the epigastrium 
and cooling drinks relieving it promptly. 2d. The general anxious 
expression of countenance. 3d. The deep sighing and occasional 
cough in the respiratory system. 4th. The colour, dryness, and mois- 
ture of the general surface. 5th. The occasional constipation, or diar- 
rhoea, of the intestines. 6th. The occasional biliousness of the hepatic. 
Bilious vomiting, I think, I met in but one case; here there were evi- 
dences of excessive hepatic secretion throughout the disease — the 
discharge furnished no relief and the fever was very obstinate and 
difficult to be subdued. On its termination the patient was quite yel- 
low. No mercurial preparation was given throughout hisdisease — bili- 
ous secretion being over free without it; and he recovered his colour and 
health in a few days, (see Case VII.) 7th. The suppression of, or 
high colour of the urine. 8th. The occasional hemorrhages, &c. 
from the uterine. 9th. And the white surface and red edges, and oc- 
casional dry appearance of the tongue. Dr. Rush remarked in the 
yellow fever of 1793 that "the tongue was in every instance moist 
and of a white colour, as the disease advanced it assumed a red co- 
lour, and red shining appearance; it was not quite dry in this state;" 



Barton on Epidemic Yellow Fever. 39 

this concurs with the general experience of writers on this disease. 
To the second belong those affecting the cerebrospinal system^ as 
pains in the head, back and limbs, and want of sleep, delirium, &c. 
That the brain and nerves are but sympathetically affected in this 
disease, besides what has been above said, is further proved from the 
fact, long ago remarked by Dr. Rush, that " it was very uncommon 
to see tremors of the limbs and twitching of the tendons in it, v/hich 
occur only in those where there was a predisposition to nervous dis- 
eases," which has been corroborated by subsequent observers, and 
the rapid recoveries from it is still further evidence of the fact, these 
occurring in diseases only in which the brain and nerves remain for 
the most part unimpaired. 

Besides these there are the direct evidences of the involvement of 
the stomach itself, known from the great thirst and desire for cold 
drinks, and the benefit in indulging in them, and anguish, uneasiness 
and pain produced by warm and stimulating fluids; the loss of appe- 
tite, the vomiting and the pain, and tension and heat in epigastrium; 
the condition of the tongue; the immediate effect of local detractions 
of blood from the epigastrium, relieving all these symptoms, and the 
influence of soup and other stimulants, producing red and dry tongue 
and delirium, instances of which will be mentioned in the cases. I 
may mention now, that an example occurred in Mr. B. of perfect 
bulimia, with all the symptoms of the fever; red, clean tongue; red, 
fiery, staring eyes; pain in the epigastrium; great thirst, desire for 
cold drinks; two or three local detractions of blood from the vicinity 
of the stomach soon relieved it and he recovered. 

Further proof there cannot be wanting of the specific and general 
inflammatory nature of the disease under consideration, for besides 
the predisposing causes and the particular circumstances, to prove 
the existence of local inflammation; the high pulse and general fever; 
the delirium; the blood-shot eyes; the white tongue, (so often enu- 
merated by authors as a proof of inflammation;) the hseraorrhages; the 
violent pains in the head, back, and limbs; its rapid termination by dis- 
organization of important organs, and almost uniformly of the stomach 
and duodenum, if not speedily arrested by depletion; the inflamma- 
tory character of the diseases that preceded it; the long continuance 
of the hot dry weather. Sydenham, Rush, Hillary, &c. have re- 
marked that diseases are made more inflammatory by this description 
of weather, and lastly the great and immediate benefit from the use 
of general and local depletion and antiphlogistics. 

Dissection showed in every case, inflammation of the stomach and 
duodenum^ and sometimes extending varying distances into the gali 



40 Barton on Epidemic Yellow Fever* 

ducts, even as far, in some cases, as the gall bladder itself; the liver 
usually unaffected; the gall-bladder containing a due portion of healthy 
bile. In intemperate subjects there is sometimes found great engorge- 
ment of the vena portse. In the congestive cases, where the system 
sunk with imperfect or no reaction, pulse unaftected, or small and 
quick, stupid drunken expression of countenance, the whole alimen- 
tary canal exhibited symptoms of the most intense devastation, even 
to effusion under the mucous membrane, and almost gangrenous de- 
generation. These appearances were extensively observed by Drs. 
Hunt and Stone at the Charity hospital, whose numerous dissections 
in such a loathsome disease, at such a season, entitle them to great 
credit. 

These autopsical researches correspond with those which have been 
usually found in this disease in various parts of the globe, fully prov- 
ing it to be gastro-duodenitis with occasional involvement of the brain, 
liver, &c. dependant much upon season and habits; but these latter or- 
gans are ^Mom primarily involved; their derangement can be relieved 
without curing the disease; they are seldom the cause of death. This 
however is not the case with the former; there can he no yellow fever 
without gastric symptoms,- there can he without cerehral or hepatic; 
tlie involvement of these latter organs is often due in a great measure 
to tlie treatment. Hepatic or cerebral stimulation must leave its im- 
pression hehind it, and how far stimulants are indicated in the disease, 
when these organs are so often already over-stimulated or liable to be- 
come so, must be answered by those who are in the habit of prescrib- 
ing that class of medicines. 

From tlie foregoing observations and physiological explanation of 
the symptoms, we presume the following corollaries will be admitted, 
viz. — 1st. That there are general symptoms o{ inflammation. 

2d. That there are symptoms of specific or local inflammation, 

3d. That the jnimary seat of this inflammation is in the stomach. 

4th. That other organs are but secondarily affected, as the brain, 
liver, &c. Upon this pathology we lay the foundation of our treatment. 

Let us proceed then to the exposition of the principles simplified 
by tliis view of the subject, and reduced in its indications, to — 

1st. Controlling or subduing the general inflammatory disposition 
of the system, produced by the primary influence of the disease on 
the most susceptible organ, and one having the greatest range of sym* 
pathies. 

2d. Subduing that inflammation itself; and — 

Sd. Removing its sympathizing consequences in the organic sys- 
tem, and system of relation. 



Barton on Epidemic Yelloiv Fever, 41 

The 1st is accomplished bj general bleeding. 

The 2d by local bleeding, by cooling drinks, &c. 

The Sd by local detractions of blood, by cold ablutions, ice mu- 
cilages, aperient medicines, enemata, pediluvia, and fomentations, &c. 

The modus operandi of the 1st. — The heart being connected with 
the stomach in the closest organic sympathy, it soon partakes of its 
irritations, and extends, by its universal action, its excitement to 
other organs, increases the extent of diseased action, embarrasses to 
that degree all the functions, and cripples the ultimate recuperative 
energies of the system by weakening its power, besides keeping up 
the irritation in its original seat: hence, then, the importance of ar- 
resting in limine the undue action of this important viscus, there is 
no mode that so rapidly and speedily affects this very often indispensable 
object as the lancet; and probably in no disease is this more essen- 
tial than in yellow fever. This is emphatically a disease which 
runs through its curative stage, (when severe,) more rapidly than 
almost any other, (cholera excepted,) seldom extending beyond thirty- 
six hours. Neglected or improperly treated beyond this period, dis- 
organization of some important organ, or some fatal congestion, is 
almost sure to occur. From these circumstances, then, the great im- 
portance of the early abstraction of blood when there exists ex- 
cess of plethora, to diminish the momentum of a powerful internal 
stimulus. I found also relief much more surely obtained, and 
much more permanent when the blood was drawn whilst the patient 
was in a horizontal posture; when taken in an erect position, 
even ad deliquum, the pain in the head was sometimes not re- 
lieved by it, or if so, would rarely continue long. It was a rule 
then with me to bleed at first, (if called early,) in the horizon- 
tal position until all pain was relieved, and to repeat the opera- 
tion at its return, provided there was much force in the pulsa- 
tions of the left ventricle, and no sufficient contraevidence of pros- 
tration. When I had thus subdued arterial or febrile reaction, and 
reduced the plethora of the sanguiferous system, and there was re- 
turn of pain, it was left to the controul of local bleeding. The effect 
of thus bleeding — when the febrile conflict had reached its height, 
seldom failed to calm the commotion in the system, prevent unneces- 
sary waste of the vital energy, by moderating the violence of reac- 
tion, quiet the irritated organs, and prevent the extension of irrita- 
tion to remote parts of the system: and I carry it so far until all the 
urgent symptoms, proceeding from excess of reaction, have disap- 
peared, or been subdued. We thereby prevent the consequences 
which we know, from reasoning and experience, will result from in- 

4* 



42 Barton on Epidemic Yellow Fever. 

flammatory congestion produced from unrestrained excess of action 
in the blood-vessels, at a time when the system is necessarily debili- 
tated from the long continuance of solar heat, occurring as this dis- 
ease usually does in the last of the summer months. 

In bleeding, my object was not so much the quantity of blood re- 
moved, as the impression made upon tlie system by the evacuation, 
and one efficient bleeding, as soon as the febrile excitement is deve- 
loped, will do more to diminish the excitement of the heart and arte- 
ries, and in subduing the violence, and shortening the duration of the 
disease, than a dozen " moderate" bleedings. These tend to diminish 
strength without controlling the disease, or removing the inflamma- 
tory or congestive tendency of the blood-vessels to particular parts — 
the heart and arteries have time to accommodate themselves to its 
loss, and thus resist the subduing influence of the measure: less 
blood then is actually expended, and the impression kept up in the 
system. Hence then the difference between Dr. Rush's bleeding 
twelve to fifteen times, taking each time eight to fifteen ounces, 
and that recommended here. The object being effect, and that 
kept up where requisite by the repetition of the bleeding to the full 
intent of accomplishing the desired end, and hence the quantity 
was an object of minor importance^ it sometimes required seventy 
ounces at first, and in twelve to eighteen hours ten to twenty more. 
But then the end was obtained — the disease was, as it were, strangled 
in its birth; the fever in but few instances continuing longer than 
twenty-four hours after these bleedings, and they produced but tem- 
porary debility. Mr. J. (Case III.) was out and well four days after 
loosing between eighty and ninety ounces of blood; while in other 
cases, not so depleted, the fever run on three or four days; and in the 
first case there was rarely a return; while with the second there en- 
sued the insidious remission on fourth or fifth day, with its fatal re- 
turn soon after — black vomit, &c. In no disease probably is it more 
necessary to bleed early, if at all, while the system having reactive 
power will respond to its impression, and it can have derivative influ- 
ence. If it be protracted, it cannot cure inflammation with deficient vis 
vit«, or remove congestion in a prostrated organism. Hence bleed- 
ing was mostly an equivocal remedy after the second day. As the 
season advanced less detraction of blood was required. The import- 
ance of using immediate means to arrest this disease, has been beau- 
tifully inculcated by Dr. Rush, by comparing it to Time, which has 
a lock upon li^ forehead, but none behind. For quantity and repeti- 
tion, see table at the conclusion of this paper, and the cases in detail. 

The second indication was accomplished by local bleeding, cooling 



Barton on Epidemic Yellow Fever, 43 

drinks, &c. As soon as the pulse was reduced by the lancet, and 
their still existed pain in the head, back and limbs, great thirst, ten- 
derness of epigastrium, vomiting — from four to eight cups, or from 
ten to thirty leeches were applied behind the ears and back of the 
neck, or to the epigastrium, and with the uniform eftect of alleviat- 
ing, and almost always of subduing the symptoms. Thus, each visit 
of the physician was truly gratifying, and little less so to him than to 
his patient — for he had the satisfaction on each occasion of evincing his 
power to afford his patient entire relief, and those who have suffered 
the agonies of yellow fever, know how great a boon that is. It was 
sometimes necessary from being called late to a patient, from his 
having taken medicines, and extended the gastro-enteritic inflamma- 
tion, from vomiting supervening, or becoming obstinate, continuance 
of fever, from recurrence of pain in epigastrium, head, &c» again to 
have recourse to local bleeding. Here leeches are much better than 
cups, and fully answer the end in view: from twenty to thirty 
should be applied to the epigastrium, usually ten to fifteen are suf- 
ficient, for their being now a great hsemorrhagic tendency, from the 
vital forces being much impaired, and from the broken down state of 
the blood, the bites will continue to exude blood, sometimes for forty- 
eight liours, relieving the gastric pains and uneasiness, vomiting and 
fever, without much increasing the debility; and this they do by di- 
verting blood from the mucous membranes, the focus of sanguineous 
accumulations. 

It is evident then that general bleeding was often not sufficient^ 
for though it extends its influence to every part of the system by les- 
sening the mass of blood, the relief is often but of short duration^ 
because the local irritation not being subdued, continues to draw fresh 
supplies of blood into the tissues, and they soon recover their preponder- 
ance over the other organs. Hence this local irritation must be sub- 
dued in a more direct manner, and the strength of the patient saved » 
but on the contrary, if local bleeding, (in a case where there is 
plethora of the blood-vessels,) is not preceded by general blood-letting, 
fresh supplies would be obtained to be poured upon the affected tis- 
sues, derived from the redundant fluid in the system. It is obvious 
then that they are different remedies — one is to the part what the 
other is to the raging torrent of the circulation. In cases of severity 
there is no substitute, it cannot be dispensed with. All disease is 
local first; its greatest; its lethal impression is local; its general im- 
pression is sympathetic; is transient It consists in active local 
over-excitement i the obvious remedy consists in local depletion from 



44 Barton on Epidemic Yellow Fever. 

the part itself, or from a neighbouring organ or part, having the 
closest sympathy or connexion with it from which it is safe. 

The well-known influence of capillary bleeding over the undue 
action of the hearty its antagonizing influence over the centre of the 
circulation 5 its removing a local irritation from which originated the 
vascular excitement^ the direct and important sympathizing influence 
of the stomach with the skin opposite^ all corroborated by the direct 
effect of these means, are each and every one, proofs not only of the 
correctness of the treatment, but of the pathology. These remarks 
are happily corroborated by very high authority, of no modern date; 
Parens and others mention cases of recovery from the plague by 
haemorrhages from the nose, &c. continuing one or two days. Rush 
mentions the same of spontaneous haemorrhages from the nose and other 
parts, curing yellow fever. Riverius also cured a pestilential fever 
at Montpellier by a gradual abstraction of blood, and Dr. Hodges 
cured the plague in London in a similar manner; "perhaps," says 
Dr. Rush, '' the uniform good effects which was observed to follow a 
spontaneous haemorrhage from an orifice in the arm, arose wholly from 
the gradual manner in which the stimulus of the blood was in this 
•^vay abstracted from the body." 

And again, he continues, he " often found the pulse so weak, quick 
and frequent, and with other signs of prostration, that he could not 
bleed; nature often relieved herself from this condition on the fourth 
or fifth day, by the discharge of several pounds of blood from the 
gums, and with the happiest effects."^^ 

The same authority and accurate observer remarks, " that plen- 
tiful sweats and discharges of purulent matter from external sores 
cures plague, and that their efficacy depends upon the gradual manner 
in which it is done, and that these discharges may be easily and ef- 
fectually imitated by small and repeated bleedings,^^ and so highly 
does he think of these gradual abstractions of "stimulus," as he terms 
the blood and secreted fluids, that he thinks ''in some future time 
the only question to be asked will be from what part of the body these 
evacuations should be procured, the order that should be pursued in 
obtaining them, and the quantity of each of the matters to be dis- 
charged, which should be withdrawn at a time ! Had that distinguish- 
ed and eminent man lived to witness the eftect of the application of 
local bleeding in febrile diseases in our day, based upon the more 
perfect physiological and pathological knowledge of the system, he 
would have had additional reasons for his professional enthusiasm and 
gratitude to heaven. 



Barton on Epidemic Yellow Fever, 45 

Dr. Williams relates the case of the recovery of a gentleman from 
the yellow fever following small haemorrhages which continued three 
days, from wounds in his shoulders made with the scarifier. The 
gradual abstraction of blood by leeches had a similar effect in our 
fever, after the second day, subduing and keeping down excite- 
ment, irritable stomach and local determinations of blood. Iced gum 
water and lemonade were freely allowed to fulfil the same indication, 
and they contributed largely to the success of my practice, and the 
gratification of the patient. It was, however, found necessary m 
some cases of great gastric irritability, to limit the drinks to the 
smallest possible quantity, and sometimes almost to suspend them 
altogether, and only to rince the mouth with cold drinks, and to chew 
ice. The latter indulgence was very valuable, and I sometimes per- 
mitted patients to swallow small portions of ice. 

For the third, besides the preceding, injections every four or sis 
hours were ordered, to keep the bowels in a soluble condition, and 
it was in but very few instances that this did not supersede every 
other. To show how little purgative medicine was required, the 
bowels were kept open by these means, and the stools were natural in 
most cases throughout the disease. Mucilaginous fomentations to the 
abdomen; when skin hot a free use of cold ablutions; ice in a towel or 
bladder to the head, and every four or six hours a mustard bath to 
feet, to equalize the excitement, and to correct or prevent undue de- 
termination to the head. The warm bath was occasionally of great 
benefit where excitement was irregular, and there existed ataxic re- 
action, to equalize excitement, and then bleeding even in the bath, 
occasionally answered most valuable purposes. Great wakefulness, 
a very troublesome symptom, was controlled without difficulty by 
free depletion from the head. Sometimes there occurred a slight de- 
lirium, sufficient to prevent the individual being conscious of what 
was passing, and recollecting the past, which was relieved by similar 
means. It was remarked that there was less danger when the pain in 
the head was, though excruciating, diffused over the entire head, 
than when confined immediately over the eyebrows. 

It was not found necessary in a single instance to resort to tonics 
during convalescence, (the appetite being already stronger than the 
digestion,) which was usually very rapid and just in proportion to the 
preceding unembarrassed state of the constitution. This was remark- 
ably evinced in several who had previously suffered under gastric de- 
rangement, (dyspepsia, &c.) and in the cases referred to in the table 
where return of appetite was protracted; it occurred in subjects who 
had suffered from protracted chronic ailments, or in latter part of the 



46 Barton on Epidemic Yellow Fever, 

season. When this was not the case, the return of appetite and 
strength was inconceivably rapid. (A gentleman informed me on 
using some soup which I had prescribed to him, that it passed like 
electricity through his system, imparting immediate strength — his 
constitution was unimpaired — see Case III.) Such as these may 
be said to have yielded temporarily to the blast, they could not re- 
sist, and as soon as it passed they stood erect with all their original 
strength and stamina. Animal food was to be resorted to at first with 
care, the original gastric irritation being easily reexcited; the stomach, 
(the citadel^) and bowels, not being impaired by the treatment, and 
unencumbered by drugging; appetite, and with it, strength, was soon 
restored. This is otherwise when treated upon a different plan, and 
the convalescence requires a different treatment; if a patient's bowels 
can withstand calomel and the drastic purgatives, he can withstand 
soup, porter, tonics, &c. while physiologically treated, he will only bear 
the mildest excitement. In the first case, the excitability of the stomach 
and bowels is worn down by the repeated drugging, if he survives; in the 
second, only reduced to the grade of recuperative restoration. Hence 
the first requires stimulants to restore the impaired energies of an ex- 
hausted constitution; the other the mildest nourishment, as a pabulum 
for constitutional support; for the treatment consisting only in means 
to reduce excess of morbid action; when that is accomplished, nature 
only requires support in her constitutional reaction. No experienced, 
candid, enlightened man will doubt, but that efficient energetic treat- 
ment influencing disease, may even alter its stages; it is the test of 
power and efiiciency; it controuls and breaks up morbid action. 
If then it influences materially the primary impression of diseased 
action, it breaks up its links, it alters its sequences, it arrests 
its associations of sympathetic action, if it directly subdues dis- 
ease and does not substitute another for it* Such in fact was the 
effect of this direct depletory mode, that in but few cases, (when 
called early and where there was a sound constitution,) was there a 
recurrence of fever; the fever when subdued, which was usually in 
from twenty-four to thirty-six hours did not return. Hence it is 
believed to be one of the best evidences of its adaptation to the dis- 
ease, the true philosophy of the profession. It is at no expense of the 
constitution. It removes that which directly tends to its destruction. 
Among the attendants on the late occurrence of the disease were 
various haemorrhages — as from the ear, uterus, or anus. My friend, 
Dr. Hunt, mentioned to me instances occurring at the Charity Hos- 
pital, to which he was surgeon, in which blood exuded from the scrotum, 
and in various cases haemorrhage occurred from the gums, in those how- 



Barton on Epidemic Yellow Fever. 47 

ever only^ (so far as mj observation extended,) where the individuals 
had taken mercury. A gentleman from the country who had but a few 
weeks recovered from a severe attack of bilious fever, in which he had 
been severely salivated, on coming to the city was seized with yellow 
fever, and suffered excruciating torture in his back, limbs, and sto- 
mach, but particularly the former^ about the third day salivation came 
on spontaneously, (for I gave him no mercury,) and he was highly sa- 
livated, without its mitigating any of the other sy7nptoms. This was 
followed by profuse and very exhausting hsemorrhage from his gums. 
He recovered, after a free use of local depletion, but his convales- 
cence was protracted, and it was some time before his appetite re- 
turned. A fetid breath was considered a very bad symptom: I saw 
but one case in which it existed that recovered, and in that case con- 
valescence was very protracted. Great restlessness and jactitation of 
body was a very bad symptom. 1 saw an instance of it terminating in 
speedy death where it was the only alarming symptom. There oc- 
curred but two cases of hiccup in my practice. There was for the first 
few days great liability to faint in the erect posture. A long walk, 
or rather run, and then plunging into the cold bath, excited the dis- 
ease in one of my patients: it proved fatal. Intemperance excited it 
in several. Fear produced it in some. Any thing that tended to de- 
stroy the equilibrium of the system, acted as an exciting cause. In 
one case there was a great and universal soreness to the touch 
throughout the body. As the disease retired, it assumed in some in- 
stances the intermittent form — became more protracted and milder, 
and almost every instance mentioned in the table of a protraction be- 
yond the eighth or ninth day, were in those occurring in the latter 
part of the season, or when the constitution had been previously im- 
paired. 

Persons of all ages, colours and conditions, who had not been accli- 
mated, were subject to the disease. It was most severe with the robust 
of middle age and of intemperate habits; it was much milder with the 
coloured, and in those coming from similar parallels of latitude; most 
ofthose from Charleston, South Carolina, escaping, though not universal- 
ly. The Creoles of the state unacclimated to the city were not exempt 
I know of no instance where it was taken a second time. In intertro- 
pical countries the disease is rarely taken twice, unless the acclima- 
tion may have been lost by a continued residence from the climate 
for some time in more northern latitudes. In this respect it differs 
from countries whose winters are sufficiently cold to destroy acclima- 
tion, or the accustomed impression of a warm temperature. 

I know of no preventive but rigid temperance, a free use of the 



48 Barton on Epidemic Yellow Fever* 

cold bath, and flesh brush; this has succeeded in persons who Were mi* 
accustomed to the city. We are not without distinguished authorities 
for the efficacy of temperance in exempting from the influence of pes- 
tilence, both in ancient and modern times; among others, it may be 
mentioned that Socrates in Athens, and Justinian in Constantinople, 
were preserved by means of their abstemious modes of living from 
the plagues which occasionally ravaged those cities. Dr. Hodges, 
Howard the philanthropist, the experienced Dr. Jackson, Dr. J. 
Johnson, Dr. Cleghorn, and Dr. Rush, confirm, by their personal 
experience, the utility of low diet as a preventive to plague and 
yellow fever. The details upon this subject are very interesting, but 
I have no room for them; they are fully confirmed by my own ex- 
perience, of now near fifteen years, in this disease. 

Such then is the result of our experience with the physiological 
mode of treatment of yellow fever; it is not confined to one year's 
experience, it is the result of five, and now for near fifteen years in 
this climate, I have treated, and seen it treated, by nearly every 
mode. The grounds of preference will be stated in the sequel. I have 
thus stated, in as succinct a manner as the importance of the sub- 
ject would admit, the indications in yellow fever, deduced from its 
pathology, and the treatment which results. The highly satisfac- 
tory result may be seen by referring to the tables at the conclusion 
of this paper, where it is established that out of my seventy-five 
cases of yellow fever, only six terminated fatally under this mode 
of treatment, or eight per cent. 

I proceed now to enter more into detail, and show the application 
of the principles and practice to the cases themselves. To show that 
these viev/s are derived from and sustained by experience, as well as 
a priori reasoning, and that they have triumphantly stood the test of 
the late epidemic. Of course, in a paper like the present I can only 
give the details of a few cases. 

Case I. Dr. M'K. aged twenty-eight, of a sanguine-nervous tem- 
perament, with great cerebral development, and highly intellectual, 
was taken on the 19th of August with chilliness, feverishness, and 
violent pain in the head, epigastrium, back and limbs, and even some- 
what delirious; having had several days of similar premonition, which 
had been disregarded in his anxiety to attend to his professional du- 
ties. The pulse was found soft, and a little upwards of 100; eyes red 
and injected; great gastric irritability, and intense thirst; red tongue 
with strawberry points. A free cupping from the epigastrium gave 
great relief; ice in a bladder was ordered to his head; a hot mustard 
foot-bath every two hours^ cool emollients and sub-acid drinks; pur- 



\ 



Barton on Bpidetnic Yelloio Fever. 49 

gative injection. About midnight pain in head returned. Cups to 
temples gave partial relief; fomentations to abdomen. 

QOth. Slept but little; symptoms returned. Cups to neck and epi- 
gastrium, which promptly relieved all the symptoms; emollient 
enemata every four hours. Attempted to give a cathartic, the stomach 
rejected it. livening. Recurrence of symptoms; slightly delirious; 
slept occasionally during the day; pulse 88; tongue same, though 
paler. Cups to neck, to entire relief. 

21s/. Slept during the early part of the night very well, latter part 
restless; some pain in head; pulse 88; eyes still red; abdomen soft; 
cupped neck very freely, to the entire relief of the head. From some 
symptoms of intestinal irritation, abdominal distention, uneasiness, 
&c. which occurred to day, (and the cause of which will be here- 
after explained, though we were then unaware of them,) it was 
deemed adviseable to exhibit a cathartic, (cathartic pills of rhubarb — 
scammony and aloes each two grains,) which was partly rejected. The 
sensibility of the stomach was increased by the cathartic, requiring 
renewed and unremitted attention to the iced mucilaginous drinks, 
fomentations, &c. to remove it. Evening. Pulse better; heat of 
skin and pulse reduced, which this morning had been higher than 
usual. 

9.2d. Slept pretty w^ell; skin cool and moist; pulse natural; free 
from pain; feels very well; some appetite; bowels natural; tongue 
cleaning; gave barley water, arrow-root, &c. 

SSfZ. Slept well; feels in fine spirits; stools natural and formed; 
urine good and sufficient; appetite. About 10 o^clock complained of 
irritation in the rectum, a frequent disposition to go to stool, with 
tenesmus, little or nothing except mucus passing. This at first 
did not at all alarm us; it was deemed an irritation under the 
controul of anodyne fomentations and local bleeding, and for five or 
six hours the pulse did not at all partake of it, nor were there any 
other evidences of intestinal irritation; when however all these means 
were found not only to have been tried in vain, but that the irritation 
was increasing, it became necessary to examine into its probable 
cause, and it was found that he was labouring under rectitis 
from the improper and unauthorized use of a large glyster pipe by 
his French nurse, who had been in the hahit of using it unknown 
to us, sometimes every half hour and oftener. Irritation now extended 
to the bladder and contiguous parts, producing indiscribable torture. 

7 P. M. Symptoms became highly aggravated and alarming; pulse 
sinking; cold extremities. Stimulants; flying sinapisms, &c. were all 
tried in vain. 

No. XXIX.— November, 1834. 5 



50 Barton on Epidemic Yellow Fever. 

JRemarks.^— Thus this patient was snatched from safety, after he had 
evidently weathered his disease. The case was extremely interesting, 
and among the earliest in which the physiological treatment had been 
tried. The prompt relief in this case from the urgent symptoms by the 
local bleeding, the gratification of the strongest instincts by coo! and sub- 
acid drinks, cool air, &c. the avoidance of offensive articles believed to 
be uncalled for by his condition, and inadmissible from gastric irritabi- 
lity, produced from the patient himself, (a highly talented member 
of the profession, but inexperienced in this practice,) the warmest 
expressions of delight and surprise, and was most favourably received 
by all who witnessed it. It was seen to be aptly accommodated to the 
objects to be accomplished, and it was obvious it fully and fairly ef- 
fected them, without suffering, or jeopardy, or loss of time. As 
much interest had been excited by the case, and he was fairly consi- 
dered to have weathered the storm, many professional friends, as well 
as myself, were desirous of witnessing the autopsy, to see how far 
it would account for such an unexpected event. Accordingly I pro- 
ceeded twelve hours after death, i n the presence of Drs. Meux, Picton, 
Hunt, Harley, Crockett and Kelly, to the examination. 

Autopsy. — Body but little emaciated. 

Stomach. Some few patches of redness near the upper orifice^ 
mucous membrane sound. — Duodenum and small intestines. Pretty 
natural. — Liver and gall-bladder. Entirely healthy; latter half-full of 
healthy, but rather concentrated bile. — Rectum and large intestines. 
From margin of the anus to twelve or fourteen inches up, the rectum 
exhibited marks of the most intense inflammation, and some incipient 
ulceration, particularly around the anus. The large intestines and 
bladder and kidneys unaffected. The heart was examined by Dr. 
Hunt; a slight speck of inflammation, if not ulceration, was observed 
on its lining membrane. 

It was not convenient to examine the head. 

From the appearances, it was the unanimous opinion of the gen- 
tlemen present that there were no sufficient disease to account for the 
unfortunate termination in this case, but that exhibited by the rectum. 

Case II. — September 23c/. B. H. aged twenty-six; six months here, 
of a sanguine temperament, was suddenly struck with a violent pain 
in head, so as to make her stupid, she was carried to bed totally un- 
conscious of her situation. I saw her in four hours, and found 
it almost impossible to get any answers to my questions, and had 
great difficulty in rousing her. She was stupid and almost coma- 
tose; eyes muddy, v/atery, and injected; skin bronzed; tongue dry 
and red; pulse 120, soft, and weak; respiration embarrassed; deep 



Barton on Epidemic Yellow Fever. 51 

sighing; eructation; extremities cold. Drewnearlyeightouncesby cups 
from epigastrium and back of ears, which having greatly liberated the 
circulation, she was then bled cautiously to twenty ounces, which roused 
her, and she could give an intelligible account of herself. Ordered 
strong hot mustard bath to extremities, and injections of salt and 
soap-suds, and spirit of turpentine every four hours; warm cataplasm 
to stomach; gum Arabic water as drink. 

24/A. Slept well last night; bowels well operated on; stupor les- 
sened; feet cold; thirst; tongue red and dry; bled to ten ounces, and 
applied cups to epigastrium and neck, and repeat the bath and injec- 
tions, &c. as yesterday. 

SL^th. Better; skin warm and moist; tongue moist; thirst not so 
great; intellect still dull, and too much disposed to sleep; bowels well 
opened; feet cool; repeat the cups behind the ears, and continue 
the balance of the prescription. 

26//i. Much better in every respect; skin and bowels good; tongue 
moist; ordered mild nourishment. 

9.7tli, Doing well; no return of fever. Discharged. 

^emarA;s.— Local bleeding is eminently useful in liberating the 
circulation, when disposed from super-irritation to be concentrated 
upon a part; this was just such a case, and so are all our worst and 
most intense grades of summer and autumnal fever, having a local ir- 
ritation as a focus of sanguineous accumulations, internal medicines 
have very early the power of removing it, their tendency is to in- 
crease it. Many years experience has convinced me that no remedy 
I have ever seen and tried, has an equal derivative and liberating 
power to cupping. Reasoning as well as experience are both in 
favour of it. In this instance I believe there would have been speedy 
dissolution without it. In such a case, there is not blood enough in 
the general circulation to permit you to detract from it. This fluid 
is in the capillary tissue. In proportion then as you remove the local 
irritation, you diffuse the circulating mass, but as the vis medicatrix 
in producing reaction, would tend, in the present condition of the 
part, to disorganization, unless its disposition to concentrating action 
was controlled, bleeding was requisite in the cautious manner used, 
to prevent it. This was accomplished, the reactive power was kept 
in check, fever was controlled, and the case did well. The condi- 
tion of the tongue showed that the gastro-intestinal surface would not 
have borne revulsion upon them, by the administration of internal 
medicine. Hence, the course pursued was the only admissible one, 
it will rarely fail, when attempted with a cautious boldness. 

Case III. — dugust 2Qth. C. M. J., a delicate, sanguineous, ner- 



52 Barton on Epidemic Yellow Fever. 

vous temperament, aged twentj-slx, eight months here, was taken 
suddenly on the 26th at 2 P. M. soon after an usual dinner, without 
any premonition, with chilliness, violent pain in head, back, and 
limbs, and feeling of malaise at epigastrium. Saw him at 8 P. M. 
and found him as above; with hot and dry skin; pulse compressible, 
but sharp, and above 100; tongue white, red edges; eyes muddy. 
Bled while in a horizontal posture to relief, which, to my astonish- 
ment, required about two quarts and a half — then the relief was per- 
fect; ordered mucilaginous fomentations to abdomen; warm mustard 
bath every three hours; towels wrung out of cold water to head, and 
surface often washed with the same; mucilaginous sub-acid drink; in- 
jection of soap-suds and salt, and to have the vein reopened if pains 
returned. 

9.7th, 6 A. M. Had passed part of the night well; skin hot and 
dry; pain in head returned; pulse 100; some tension of epigastrium 
and uneasiness of back; tongue white, with red edges. Bled to re- 
lief, which required §xx. ; ice in bladder to head; directions con- 
tinued . 

10 d. M. Some uneasiness of head and epigastrium. Cupped epi- 
gastrium with entire relief; directions continued. Night. Pulse com- 
fortable; no uneasiness; bowels well moved; stools natural; skin be- 
came gradually cool; pulse reduced to 88. 

28^/i, ^ Ji. M. Passed a pretty good night; skin rather warm; ab- 
domen soft, though little doughy; some dull pain in head; feet, (which 
had been rather cold heretofore, by increasing the strength of the 
bath,) had become very warm. Cupped freely from neck and behind 
ears, with entire relief, and gave a wine-glass of sweet oil. Midday. 
Oil operated well; natural stools; pulse 92. Night. Much better; 
skin cool; no fever or thirst; eyes clear. 

29^/i. Much better; slept well, but sweated profusely; pulse 84; 
tongue moist and clean, and pale eyes; some appetite; abdomen soft. 
Continue directions, but lengthening the interval of application. Or- 
dered some very weak chicken water. Afternoon. Feels very well; 
soup revived him very much; feels much stronger; walked several 
times across the room; pulse 7Q, soft and full; expression very good, 
and every symptom of convalescence. 

30/^. Slept well last night; sweated too freely; weakened by it. 
Ordered flesh brush to entire surface, (his in die.) Tongue clean; 
pulse and abdomen natural. Convalescence established; walking 
about the house. Soup, mush, &c. 

^\st. Slept well; no night sweat; appetite good; feels well; walked 
out to business. 



I 



» Barton on Epidemic Yellow Fever. 53 

Remarhs. — This was an ordinary case, where the disease went 
through its usual progress in a sound and unembarrassed constitution, 
and is a fair specimen of the treatment. Mr. J. is delicate; tempe- 
rate; totally unaccustomed to the climate, and had every symptom, 
from its suddenness and violence, of a severe attack. It promptly yield- 
ed to the treatment — every indication having been immediately fulfill- 
ed, and though a very large detraction of blood was required to controul 
the extent of morbid action, yet the patient did not feel incapacitated by it 
to attend to his professional duties on the fifth day, though the weather 
was unfavourable. It is hardly too much to say, that under similar 
circumstances yellow fever would not be more alarming, or more 
fatal, than intermittent fever. This gentleman had no childish fears 
about the result to mar the treatment, and had every confidence in 
the course, which he knew to be new, and met it like a man. 

Case IV. — August 2,9th. 0. W. aged twenty-one, of a sanguine, 
bilious temperament, resident here eighteen months, taken with a 
chill followed by high fever, and pain in head, back, and limbs, &c. ; 
found him in this condition; three hours after covered with blankets, 
in profuse perspiration; pulse 125, full, bounding, though very com- 
pressible; skin hot; eyes red; tongue white, with red, fiery edges. 
Bled to about sixty ounces before perfect relief; removed blankets, 
and gave cool emollient drink; injections; baths of mustard to ^eet, 
as above, every three hours, and ice to head. In four hours pain in. 
head had returned; reopened vein, and took sixteen ounces, pre- 
viously applying six cups to epigastrium, which seemed to develops 
and give additional vigour to the pulse; it was now reduced, and 
all the symptoms relieved. Midnight. Was called on account of paia 
in head returning; cups to side and neck relieved it entirely. 

30^/i. Found him better, but pulse 106; skin hot, and occasionally 
dry; had slept pretty well after midnight; tongue getting paler, but 
seemed loaded posteriorly. Six cups to epigastrium, which gave great 
relief, and opened the skin and cooled it; ordered a table-spoonful of 
castor oil. Afternoon. Better; oil operated well, though it irritated 
him, keeping up the pulse to 98, with warmth of skin. 

Sls^. Slept well; skin getting cool; pulse 88; bowels and urine 
good; tongue white and somewhat loaded, edges pale. Continue 
treatment. Midday, Same, but cooler; pulse 74; feels comfortable^ 
Night. Same; feels well. Continue. 

September 1st. — Slept very well; feels some desire for food; pulse 
74; skin rather too warm and dryish; head cool; tongue somewhat 
loaded, and pale on edges; urine and stools natural. Ordered some 
gruel to drink as before. Midday. Pulse 84; skin warmer; feet rather 

5* 



54 Barton on Epidemic Yellow Fever.* 

cool. Ordered mustard bath to feet, and cool emollient enemata. 
Night, Skin too hot; pulse same, though more tense, and some tension 
of epigastrium, and occasional pain there. Applied five cups to epi- 
gastrium. 

2(7. Slept pretty well, and felt much relief after cupping; pulse 
84; skin cool and moist; abdomen soft; stools natural; urine plenty, 
though high-coloured; no pain; tongue still loaded, hot; some appetite. 
Treatment continued, but intervals lengthened, and gave arrow-root. 
Midday. Same, though skin too warm and dry, and bowels not 
sufficiently opened by the enemas. Gave magnesia. Night, Medi- 
cine operated; stools natural; patient fainted on pot, to which he would 
get up; skin cooler; pulse softer. Continue baths and emollient 
drinks. 

3(Z. Slept badly; skin too warm and dry; pulse 80; appetite strong; 
tongue paler, and somewhat loaded, though mouth too dry; some lit- 
tle tension in epigastrium; eyes good colour. Continue emollients; 
arrow-root gruel, &c. Midday, Has slept several times; some hae- 
morrhage from gums. 

Ath. Symptoms same; had slept well; skin rather warm and dry, 
except when he used foot bath; bowels natural; stools formed; felt 
weak, and nurse gave sangaree^ and he was a little flighty after- 
wards. Midday. Some colicky sensations and feeling of heartburn. 
Gave ginger tea; carb. pot., and ordered some very weak sangaree, 
which relieved it. Night, Easy; had talked a little wildly in his 
naps several times. 

5th. Slept part of the night, latter part badly; tongue dark from 
blood from gums, and some part of night talked wildly; feet rather 
cool. Blisters to legs, and continue. Midday. More wild; had taken 
too much port-wine sangaree, and some more bleeding from gums 
and ear, which has been very free; every other symptom, pulse, 
bowels, urine, and skin good. Ordered gargle of alum; coffee; arrow- 
root; weak chicken soup. Evening. Appeared much better. About 
midnight became more flighty; hjemorrhage from gums had somewhat 
ceased. Applied morphia to blistered surfaces, which procured some 
hours repose during afternoon. At night more delirious; urine abun- 
dant; no black vomit; commenced sinking, and died during the night. 

Remarks. — The immediate cause of the disease in this case may 
be ascribed to the great imprudence of the use of a cold bath after 
excessive fatigue during the heat of the day, and after profuse sweat- 
ing, and on an unacclimated individual. I thought at the time that 
the sangaree on the 4th had done some injury — acting upon an ex- 
citable individual, and increased the predisposition to gastro-cerebral 



Barton on Epidemic Yellow Fever, 55 

irritation, to which his temperament rendered him so liable. The 
bleeding from the gums very much prostrated him, and doubtless 
arose from a large dose of calomel, (twenty to thirty grains,) which 
he had taken before I was called. He was much alarmed throughout 
the disease, which was much against him, though he had every en- 
couragement from devoted friends and a kind nurse. He had been 
subject to a purulent discharge from his ear from infancy; the hsemor- 
rhage from that surface was not surprising. He was subject also to 
pain in the head, probably arising from the same cause, which was 
difficult to keep under during the disease, and rendered the use 
of stimulants excessively injurious. The termination at last was 
unlooked for, even with these additional embarrassments, for the 
constitution was a good one, and the symptoms of disease seemed 
to have been removed almost as soon as they originated. My 
after experience, however, convinced me, (and it was a practical 
point of great importance, giving rise to much reflexion and ob- 
servation,) that leeches would have answered much better than cupping 
on the 1st, from their gradual and continued abstraction of blood| 
for in this stage of the disease I found afterwards that blood would 
continue to ooze from leech-bites in proportion to their size, quan- 
tity, and condition of the patient, so as to be graduated almost at 
pleasure; the discharge then has a better effect in counteracting the 
tendency of morbid action to concentration wlien the organism is 
near prostrated, forces more sunk, and less able to resist the en- 
croaches of disease. All this was fully verified hj subsequent ex- 
perience. 

Case V. — ^September 4th. J. 0. J. aged twenty-nine, unacclimat- 
ed; resident here two years; of a bilio-melancholic temperament; 
looked and felt very bad, with red, watery eyes, for a week or ten 
days. On night of 3d had set up with the corpse of a deceased friend, 
and drank more than usual; felt bad; feverish; restless; pain in fore- 
head, back, and soreness of limbs: called to him on 4th, at 10 A. M, 
and in addition, found his eyes very red, blood-shot and watery; 
tongue red and dryish; pulse 124, Bled to fifty ounces before the 
pains in head and back gave way; pulse reduced in force, not in fre- 
quency; ordered six cups to epigastrium, and emollient cataplasm af- 
terwards; hot mustard bath to feet every four hours, and injections 
of oil, molasses, salt; ice to head. Midday. No pain; more com- 
fortable; tongue still dryish. Continue. Night. Tongue dry; pulse 
same; skin moist; no pain; bowels well opened; stools and urine na- 
tural. Six cups to epigastrium; continue directions. 

5th, Passed a good night; skin and tongue, (though a little red- 



56 Barton on Epidemic Yellow Fever. 

dish,) moist, and feels much more comfortable; pulse 100; stools na- 
tural. Continue. Midday. Slept some; feels better; skin good; eyes 
better; tongue moist; pulse 80; tendency to cold feet; strength of 
mustard footbath increased, cold to head. Continue. Night. Same; 
stools and urine natural. Continue. 

Qth. Slept only partially; feels uncomfortable; soreness of muscles; 
restlessness; some tension in epigastrium; pulse 84. Ordered sixteen 
leeches to epigastrium; bath continued, &c. Midday. Leeches drew 
well, and they continued to bleed; feels much better; tongue moist; 
slept some; pulse 80. Gave him gum Arabic lemonade, which he 
found very refreshing. 

7th. Slept well; pulse 72; skin soft and moist; tongue pale and 
moist; epigastrium soft; bowels open; eyes getting clear. Continue 
mild drinks; enemas; ordered gruel and arrow-root. Midday. Same. 
Appetite. 

Sth. Doing well; slept well; appetite. 

9th. Well. Discharged. 

Remarks. — Here was a case of great violence, and portending a 
rapid termination, scarcely at all yielding in its aspect, (except in 
the violence of the pains,) for about twenty hours, though there had 
been two copious bleedings, and two cuppings, &c. until the continued 
depletion from the leech-bites confirmed and rendered final what the 
others had only begun; moistened the parched tongue; cleared the 
muddy, bloodshot eye; and gave repose to the agitated system. 

Case VL — September 7th. M'H. aged twenty-four; a resident 
fifteen months; of a full, plethoric habit, sanguineous temperament; 
was taken with severe head-ache, chilliness, and high fever at 2 P. 
M. on 7th; sometime after four I found him, in addition, with high pulse, 
of 125; eyes very red and injected, and watery; pains severe in head, 
back and limbs; in a profuse perspiration, covered with blankets, and 
skin very hot; pulse not very strong, or of much force, such a pulse 
as to be expected from such a state of the skin; bled to twenty ounces 
to relief of pains; ordered iced lemonade, cataplasms, enemas, pedi- 
luviae, as in other cases; in two hours the pains returned; reopened 
the vein and drew sixteen ounces to relief. Treatment continued. 

%th. Passed a pretty good night; fever continues; pulse 116; some 
pain in head and back; six cups to epigastrium, and two to neck. 
Continue treatment. Midday. The cups relieved the pains mostly; 
some pain and heat about the head; two cups to side of the neck. 
Night. Pains removed; fever continues; pulse 100; skin soft and 
moist; heat of head and hands; ordered ice in bladder constantly to 
head; and wash skin when hot and dry with ice water. 



Barton on Epidemic Yellow Fever, 57 

9th. Better, and slept well; pulse 92; too hot, though moist; bowels 
open and natural. Continue treatment. Midday, Same; eyes still 
rather injected. Night, Easy; feels better; pulse 84. 

10th, Better; slept well; tongue almost clean; bowels open; stools 
natural, as have been throughout; eyes still injected; no pain; skin 
good. Evening. Doing well; pulse 76; slept. 

11th, Doing well; bowels, skin, natural; some appetite; gave gruel 
and rice water. Midday, Vomited twice some dark, fl(^^y matter^ 
like coffee-grounds; gave ice to chew. Night. Doing well. 

12/A. Doing well; slept well; no nausea; appetite; ordered some 
very weak chicken water; frictions with the flesh brush to surface 
twice a day. 

lAth, Eat too much, (a whole squab,) produced feverishness; or- 
dered abstinence; cooling drinks; bath. 

15th. Well; discharged. 

Remarks, — This was also a case of great violence, with strong de- 
termination to the head, eyes very much injected, and a disposition 
to coma, so much so, that though he answered questions intelligibly, 
yet for the first five days he was scarcely conscious of any thing that 
passed. It resisted for several days the most determined depletion^ 
but finally yielded to perseverance. The tongue gradually became 
pale and clean, the bowels were kept sufficiently open, several eva- 
cuations per day by injections, without cathartic medicines, and under 
this mode of treatment it can be easily effected in this way, nine 
times in ten, and hence the stomach is saved the irritation they never 
fail to produce, and great advantage is thus gained by it. I had also 
to contend with a stupid, inattentive nurse, and hot room. This case 
also proves, as does many others, that a case in which Mack vomit oc- 
curred is curable in patients, the energies and capacities of whose 
stomachs have not been impaired hj over-drugging, and the recupera- 
tive energies of nature not crippled or destroyed. 

Case VII. — Sej)temher 10th. P. D- aged about thirty-two, bilious 
temperament, resident eighteen months, taken with chilliness and 
violent pains in head, back, and limbs; red and glassy eyes, with high 
fever; pulse full, 120, though not tense, but compressible; tongue 
white, with red edges; bled to thirty ounces to relief; vomited during 
the bleeding some bile; ordered cold applications to the head, arms, 
and surface generally; mustard bath to feet; injections of oil and salt| 
bath for four hours. Midday. Pains returned; fever continues; pulse 
full, strong, and developed; bled to relief, which now required twenty- 
ounces. Continue treatment. Night, Something easier; stools na- 
tural. 



S8 Barton on Epidemic Yellow Fever. 

11th. Passed a restless night; heat of the surface continues; pulse 
much weaker; eyes and tongue same; six cups to epigastrium; ice to 
head; and continue treatment. Midday. Easier; skin moist, but lit- 
tle hot; pulse reduced. Night. Skin still hot; persevere in cold ap- 
plications. 

\9,th. Passed a restless night; some pain in the head; stools natural; 
pulse 104; tongue paler; cups to neck and behind the ears. Midday. 
Easier; skin moist; less heat. Night. Easier; skin moist, though, 
hands and head too hot; and vomited twice some bile with much mu- 
cus; though stools quite natural by injections; iced barley water; and 
continue treatment. 

l^th. Rested better, though but part of night; head too hot, and 
some pain over the eyes; eyes too red; pulse 90; three cups behind 
the ears; the cold applications; injections and bath persevered in. 
Midday. Much better; profuse perspiration; skin reduced to natural 
temperature; bowels good; some sleep. Night. Easy; continue. 

14:th. Slept pretty well; feels better, though stomach weak; gave 
barley water and gruel iced, in small quantities, and order two tea- 
spoons of oil; as tongue pale, but loaded at back and middle. Midday. 
Oil operated several times; feels pretty easy. Night. Easy; pulse 
84. Continue treatment. 

15th. Slept well; tongue still pale, though foul; feels better; no ap- 
petite; pulse 7^', continue. Midday. Better; walked across the 
floor; some desire for light nourishment; gave arrow-root, and continue 
directions at longer intervals. 

IQth. Slept well; feels much better; tongue clean; appetite; pulse 
76; ordered chicken water. Midday. Walking about; better. 

ITth. Doing well; eyes and skin tinged of a yellow hue, and some 
symptoms of jaundice; stools light-coloured. Allowed light food. 

18^/i. Doing well; had slept well. Night. Convalescent; dis- 
charged. 

Remarks.*— Thh is the only case v/hich exhibited bilious symp- 
toms, several times vomiting bile and evincing much gastric as 
well as hepatic irritability throughout, and hence the obstinacy of 
the febrile symptoms, demanding much local depletion to remove them; 
the evacuations from the bowels were natural throughout, no mercury 
was exhibited, there was not presumed to be any indication for it, 
having no faith in the regulating power of mercury, and believing it 
a specific stimulant to the liver. I saw no indication for its use, 
when there was already an overflow of its secretion. In bilious fevers 
I had often seen jaundice and torpid livers follow the profuse or 
long-continued use of mercury. It is to be hoped that correct observa- 



Barton on Epidemic Yellow Fever, 59 

tioTi, enlightened by proper experience, will be substituted for a de- 
fective theory and worse practice. 

Case VIII. — September 14th. G. L. B. aged twenty, of a full bi- 
lious temperament, nineteen months resident. Taken in night with 
chill, and very violent pains in head, and calves of legsj high fever 
followed, with thirst; red, injected eyes; pulse 120, full, and very com- 
pressible and soft; tongue white, with red edges. Saw him at 11 o'clock, 
and bled him while sitting until fainting, though pain in the head 
not relieved; laid him down, and after re'action fully returned, con- 
tinued the bleeding until entire relief, which required thirty ounces, 
and ordered mucilaginous drinks and fomentations to abdomen, in- 
jections and mustard pediluvium every four hours, &c. 5 P. M. 
Was removed a few squares in a carriage, and pains soon returned; 
pulse stronger; reopened vein and bled to relief, which now required 
twenty ounces, and prescribed as before, and cold to the head. 

\5th. Slept pretty well; pulse 116; skin cool; and some pain in 
head; stools good; tongue white; six cups to epigastrium, which re- 
lieved head, and he felt better. Midday. Easier; skin cool; pulse 84, 
Night. In sitting up to take foot bath, against directions, (for in this 
disease they are so liable to faint in the erect position, and it is so 
hazardous in a prostrated organism,) he nearly fainted; head after- 
wards aftected; delirium and fever followed; ordered ice to head, sis 
cups to epigastrium, and two behind the ears, which gave great relief; 
skin became cool and moist. 

IQth. Slept but little; talked wildly, occasionally; pulse 100; skin 
too hot; tongue white; bowels natural; but little thirst; answers in- 
telligibly; three cups behind the ears; ice to head. Midday. Feels 
much easier; skin cool and moist; bowels good; slept some; seems 
sensible; continue. Night. Head too hot; feels very well, though the 
nurse says he talks to himself; three cups behind the ears; no pe- 
diluvium, the last night it was too hot and strong, and acted as a sti- 
mulant instead of a revulsive. 

17th. Slept pretty well; eyes better; tongue paler on edges, though 
still white on surface; pulse 88; skin moist and heat reduced. Midday. 
Doing well; pulse 84; skin and tongue same. 

l%lh. Slept well; feels much better; expression good; tongue more 
flabby; the milky-whitish coat nearly removed, and a paleness sup- 
plied its place. Evening. Same; light nourishment allowed. 

l^th. Slept well; pulse 76; skin, tongue, and bowels good; order- 
ed light soup; egg during day. Evening. Some heat of the skin; pulse 
88; head-ache; eat too much. Ordered orange-flower syrup and water 



60 Barton on Epidemic Yellow Fever, 

iced in tea-spoonful, at a time, and often | cold to the head and sur^ 
face; injections; foot bath, and abstinence. 

9.Qth. Slept well; feels well; pulse and skin very good; tongue 
pale and shrunk on edges; some whitish fur. Ordered arrow-root; 
gruel; barley water; frictions to surface; had a natural stool. Dis- 
charged. 

Remarks.— T\\[% was a case of great severity; the patient was con- 
scious of but little that passed the first four or five days. A kind of 
stupor steeped his senses; there existed great tendency to affection 
of the head, only to be controlled by a rigid and extensive use of to- 
pical depletion and refrigerants; we could not produce revulsion upon 
the stomach and bowels — for the cerebral irritation was but sympa- 
thetic of a primary irritation there^ and could not safely induce it on 
the extremities to any extent, for there was too much heat; hence 
then the local, depletory treatment was the safest and most direct — 
in fact, the only admissible treatment. 

Case IX. — September Mth, T. P. aged about thirty-three, of a 
full, plethoric, corpulent habit, and sanguineous temperament, resi- 
dent several years, (except summers,) was taken with a chill on 23d, 
followed by fever, &c.; saw him on 24th, at 6 o'clock, A. M., and 
found him with fever; hot, dry skin; pulse 110; head-ache, and occa- 
sionally delirious; tongue white, with red edges, and had spent a 
very bad night. Bled him to relief, which required twenty ounces, 
and ordered ice lemonade; injections; baths, &c. (as usual.) 

Q5th. Slept but partially, though feels better; pulse 98; tongue 
same; some head-ache; head and skin generally hot, though soft; 
bowels open. Continue directions. Midday. Same; rather more 
feverish, and increase of pain in head. Ordered cups to epigastrium 
and neck; continue other directions. 

2.6th. Passed a bad night; slept but little. I now understood that 
the cups yesterday drew but little blood; felt hot and feverish; skin 
dry. Ordered fifteen leeches to epigastrium, and two cups behind 
ears. Evening. The leeches and cups drew a large quantity of blood, 
and gave great relief; he soon fell into a gentle sleep and free per- 
spiration, and now feels much better; eyes look clearer, and expres- 
sion good; had two natural stools; pulse 88. 10 F. M. AVas called 
to him; had at 9 o'clock suddenly and without any premonitory symp- 
tom, except occasional belching of wind during the day, and huskiness 
about the throat, ejected a quantity o^ black vomit from the stomach, 
and thrown to a distance without straining or effort, (the usual pecu- 
liar circumstances attending it;) had been restless, and had just takefn 



Barton on Epidemic Yellow Fever, 61 

tlie foot bath: it alarmed him very much. Ordered him to chew and 
swallow small pieces of ice, and to take iced gum water in small 
quantities, and to be perfectly still, &c. 

9Jth. Was awake to 3 or 4 o'clock, A. M. from mental uneasi- 
ness — then slept pretty well a few hours; had a black liquid stool, 
about a pint; pulse 92; much agitation of mind; frequent sighing; 
skin soft; head easy; leech-bites still continue to bleed freely. Or- 
dered continuance of advice of last night. Midday. Slept very easily; 
feels better, and more composed. Dr. Rogers, (one of our oldest and 
most experienced practitioners,) visited him to day. My views were 
concurred in. Continue treatment. Evening, Feels easy; slept; skin 
soft and moist; pulse 88; head easy; tongue paler, injection of flax- 
seed tea. Continue former directions, and syrup of gum Arabic for 
drink. 

28^A. Slept well; pulse 84; skin and head easy, soft and moist; feels 
some appetite: the injection operated twice — the first consisted of only 
a little dark-coloured water — the second was a good mushy, bilious 
stool; feels much better; eyes and skin somewhat tinged; vomited this 
morning some rancid lemonade, which had been imprudently given 
him, and over-quantity of drinks taken during the night. Ordered 
arrow-root, &c. Midday. Much the same; doing very well. Dr, 
Rogers left the case, not deeming further attendance requisite. 

Q9th. Passed a pretty good night, and feels much better; skin 
good; pulse 80; considerable appetite; desired claret and water, re- 
fused him; asked for soup; ordered some very weak chicken water 
made of a very young fowl, of which he was to take a very small 
portion; stools good; skin yellowish. Evening. Found skin too 
warm; pulse 92; tongue reddish along the edges; talks a little wildly; 
soup made too rich, and took three times as much as allowed. Order- 
ed cooling drinks and ice to head; injections, and mustard bath to 
feet, &c. 

SOth. Passed a bad night; restless and delirious; tongue red; pulse 
102, small and rather soft; extremities apt to become cold, and spleen 
enlarged. Ordered a blister to back, to spleen, and calves of legs; 
injection of oil every four hours; iced lemonade; ice to head; sina- 
pisms to feet and hands occasionally. Midday. Much the same; 
slept a little; answers questions intelligibly, though talks wildly to 
himself; skin moist; pulse 108; eyes and skin very yellow? evidently 
and deeply jaundiced. Night. Same; passed a good stool: dozes oc- 
casionally. 

October is/. —Slept but little last night; pulse 108, and soft; edges 
of tongue very red, white on surface; abdomen rather distended. 

No. XXIX.— November, 1834. 6 



62 



Barton on Epidemic Yellow Fever. 



Give two tea-spoonfuls of castor oil, with orders to repeat every three 
hours till passage. Continue treatment. 

9.d. Condition same; very deeply jaundiced; bowels free and 
somewhat bilious; continues delirious, and tendency to coma. 

3d Unaltered. Treatment continued. Died at night. 

Remarks. — In this case the first twelve hours was lost, vi'hich was 
very important. On the 25th the local detractions of blood by the 
cups was very imperfect, therefore but little benefit resulted from 
them: notwithstanding these serious impediments, and the great alarm 
he felt throughout the case, here is an instance of a free liver, having 
hlack vomit and black inky stools on the fourth day — surviving: and 
it must be evident, from precedent and subsequent circumstances, 
that the condition to form it must have been made previous to the ap- 
plication of the leeches, and the alteration must he ascribed to them, 
it having been long proved by dissections and observations of our 
distinguished countryman, Dr. Physick, in 1793, and corroborated 
by multiplied experience since, that black vomit depends upon a se- 
cretory irritation of the mucous membrane of the stomach, to be pre- 
vented by subduction of its excitement, as has been proved to me at 
least three times during the present epidemic; but this case not only 
survived it, but the entire condition wsiS changed — tone of the sto- 
mach and bowels, and their secretions, in a great measure, restored; 
bilious and natural stools supervening, and in the opinion of one of 
the veterans of the profession, evidently getting over it. This conti- 
nued several days, with constant proofs of amendment, and the re- 
lapse on the 29th, (for no one could call it any thing else,) was un- 
questionably produced by the soup, overtasking the enfeebled diges- 
tive power of an important organ — producing primarily gastro-duode- 
nitis, and as a consequence, jaundice, and then cerebritis, and at a 
period when it was no longer safe to attempt to reduce local action 
by local depletion, with diminished power and prostrated forces. 

These are all the cases my limits will permit me to set forth in de- 
tail. A synopsis of the whole is to be found in the following tables, 
which will fully sustain the claim to successful treatment. 

Malysis of the principal Symptoms observed in Yellow Fever during ike Epidemic 

at New Orleans in 1833, with the Treatment^ Besults, &c. 

SYMPTOMS. 



Epigastrium. 


&0 

c 


■a 

s 


III 


Period of Return of Appetite. ] 


1 


i 




1 
7 


4 
14 


14 


1 
-S 

o 

7 


a 

00 

2 


17 


Nearly all. 


Nearly all.* 


4 


Nearly all. 


1 



Four had black vomit, of whom two recovered. 



Barton on Epidemic Yellow Fever. 



63 



SYMPTOMS. 



Tongue. Eyes. 



•^h 



6'Remajn- 
ling ]\ o. 



10 



Expression. 



55 



38 



11 



intestines. Skin. 



59 6 



Urine. 



2* Almost '5 
all. I 



2t5t 



<:2 rt 



2t 



* In one of these the suppression was relieved on the third day, and the pj 
tient recovered. t All these recovered. 

SYMPTOMS. 



Sleep. 


Pains. 


1 


'V 


rJ 


§ 



1 


1 


1 


M 




35 


6 


10 


66 


60 


60 


1 


10 



GENERAL HISTORY. 



Attack. 


Period of Cessa- 
tion of Fever. 


Period of Discharge. j 


§1 

WD 


1 


^ 
'^ 


i 


CO 


1 




1 


^ 

-« 

1 


1 




00 


1 


•5 



.a 


,5 




i 

•a 
1 


3 


26 


5 


38 


10 


4 


10 


14 


14 


10 


4 


4 


2 


2 


1 


1 


1 


1 



TREATMENT. 



BLOOD-LETTING. 




General. 


Loc«/. 


OPENING REMEDIES. 





6 

1 


1 






.3 




•i3 




i> 


o> 


1, 

|2 


1 
1 


33 


12 


1 


19 


13 


3 


8 


1 


1 


3 


1 


23 


All. 



The other remedies employed, were baths, hot and cold; cataplasms, ice, le- 
monade, and emollient drinks. 

RESULTS. 

Recovered, 69. Died, 6; of these, 1 died from imprudent and unauthorized 
use of the glyster-pipe by the nurse, after every appearance of recovery, see 
Case I. 1 died from hsemorrhage from the gums, in consequence of having 
taken a large dose of calomel before I was called, see Case IV. 1 died from 
want of proper attendance — no nurse; room over a nine-pin alley, the noise from 
which prevented his sleeping at a critical time. 1 from relapse, brought on by 
strong soup taken on the eighth day, see Case IX. 

Mw Orleans y June^ 1834. 



64 Kirkbride's Cases treated m the Tennsylvania Hospital, 



Art. III. Report of Cases treated in the Pennsylvania Hospital. By 
T. S. KiRKBRiDE, M. D. one of the Resident Physicians. 

vyASE I. Fracture of the Skull with Depression, — Thomas Wilson, 
set. 46, labourer, received a blow upon the right side of his head from 
a heavy hand-spike, on the 1st of October, 1833, at 1 P. M. He was 
brought to the hospital one hour afterwards. When admitted was 
partially sensible, but unable to answer questions; skin cool; pulse 
weak; pupil contracted; had vomiting. The head was shaved, and a 
large effusion of blood found to exist under the scalp; a fracture was 
also detected in right parietal bone, with some depression. Sinapisms 
applied to extremities; external heat, and stimulating enema. At 3^ 
P. M. re'action commenced very slowly; soon after seemed disposed 
to sink into a state of insensibility, although at times very restless, 
and has spasmodic motions of the arms; temperature still cool. Cold 
applied to head; warmth continued to feet. At 5 P. M. reaction was 
so fully established, and his pulse had acquired so much strength 
that a vein was opened in his arm, and about ^x. of blood taken: 
was more quiet for a short time, but the state of insensibility into 
which he had for some time been falling continued to increase, and 
at 61 P. M. he had stertorous breathing, with a full and labouring 
pulse; pupil still slightly contracted. V. S. §xvj., producing little 
effect on pulse or respiration. 

He was seen by Dr. Barton at 7 o'clock, and a consultation of 
the surgeons of the house called immediately, but while preparations 
were making for operating, his respiration became still more la- 
borious, pulse sank so as not to be felt at wrist, and he died at 7h 
P. M. 

Autopsy, fifteen hours after death — Head, No external wound. 
Upon making an incision into the scalp, a large quantity of effused 
blood was found between it and the cranium. A quadrangular portion 
of bone nearly three inches in diameter, depressed, consisting princi- 
pally of the anterior and inner part of the right parietal bone, and 
extending across the sagittal suture half an inch on the left; from this 
a fracture extended about two inches and a half into the frontal bone; 
a fissure separated at upper part one-fourth of an inch, extended over 
the left side of head, and could be traced to the base of the cranium. 
A fracture also ran posteriorly from the depressed portion of bone, 
commencing half an inch to the right of the sagittal suture, passing 
obliquely across it, till it met the lambdoidal. Three openings 
existed in the dura mater, one of which was large enough to ad- 



Kirkbride's Cases treated in the Pennsylvania Hospital Q5 

mit the introduction of a finger; longitudinal sinus opened by a spi- 
cula of bone. About one gill of blood below dura mater; copious ef- 
fusion of blood into the ventricles, and a large quantity, liquid and 
coagulated, at the base of the brain. Total quantity of blood effused 
beneath the cranium, §xiv. On the left side of longitudinal sinus, 
and near the point at which the opening existed, the cerebrum was 
reduced to a soft mass to the depth of an inch and a quarter; other 
parts firm. 

Other organs not examined. 

Case II. Fracture of the Skull with Depression. — Thomas Fox, 
ast. 30, labourer; admitted April 3d, 1834. While engaged in blast- 
ing rocks, a few hours before, he was injured by an explosion; he 
was alone, and is unable to state the cause of the accident or attend- 
ing circumstances; he was stunned, and on recovering walked nearly 
half a mile before he received assistance; he also states that after he 
became sensible, was chilly and had vomiting. 

A large portion of the scalp was turned off, and a portion of skull, 
about one and a half inches square, denuded of pericranium,, on the 
inferior and middle part of right parietal bone; a fracture was disco- 
vered at this part one inch in extent, into which a piece of leather, 
apparently a part of the lining of his hat, had been driven; there was 
also a small portion of the bone slightly depressed, circular, and 
nearly one- fourth of an inch in diameter, and a cut in the forehead 
extending to the bone. The leather was removed from fissure, and as 
he complained of severe pain, Tr. opii, gtt. xl. was administered; 
wounded parts of scalp kept in apposition by simple dressings. 

5th. Has slight fever, but little pain in head; purge given yester- 
day operated freely. R. Ant. tartar, gr. ij.; Aquae, §viij. Ft. sol. 
S. §ss. every two hours; low diet. 

^th. Less tension of scalp; considerable ecchymosis about the 
face; upper part of scalp united; suppuration commencing; slight 
fever; head-ache slight; pupils natural; bowels open; pulse 84; slept 
well. Poultice scalp; continue sol. ant. tart. 

7th. Last evening patient was restless; complained of pain in head; 
fever; pulse full and rather firm; wild expression of the eye; he was 
bled ^xv. which induced faintness; the solution of antimony has been 
suspended, having produced vomiting. Better this morning; pulse 
84, soft; less thirst; skin natural temperature. R. Mist, neutral, 
^ss. every two hours. 

12/A. Large purulent discharge from scalp; no head-ache; pulse 
rather weak; he sleeps well, and has improved diet. 

\7th. No unpleasant symptoms; poultice continued to scalp. 

6* 



66 Kirkbride's Cases treated in the Pennsylvania Hospital. 

9,5th. For a day or two past has complained of head-ache, and in- 
ability to sleep at nighty pulse rather quick but weak; tongue na- 
tural; no increased heat of surface; wounds of scalp have healed, ex- 
cepting over exposed bone. Apply blister on back of neck, and keep 
it open with dressings of savin ointment. 

30//i. Head-ache much diminished; sleeps better; pulse 80, soft 
and regular; bowels kept open with sulph. magnes. 

May 8th. — Blister kept open on back of neck; free discharge from 
scalp; no head-ache, or other unfavourable symptom. 

ISth. More tumefaction of scalp; pain externally; free discharge 
of pus; bone becoming loose. Continue poultice. 

Q9th. A portion of cranium, including both tables, is nearly de- 
tached; patient occasionally has slight head-ache, which is generally 
removed by a brisk purge. 

Slst. The detached portion of cranium, about one inch square, 
was removed to-day, by cutting down upon the parts; dura mater be- 
neath healthy; patient has no head-ache; pulse slow and soft; sleeps 
well. 

June Isi. — Head-ache last night and slight fever; tongue furred. 
Ordered purge and mustard foot bath. 

2d. No fever, nor head-ache; wound granulating. 

20th. Patient has had no head-ache since last report; wound nearly 
healed; well in every other respect. 

Slst. Discharged. 

Case IK. Fracture of the SkulL — William Northern, set. 47, la- 
bourer; admitted April 23d, 1834, at 7 P. M. Is of intemperate 
habits;' has generally enjoyed good health; was struck on the head by 
the crank of a crane, at which he was employed hoisting logs, about 
one hour previous to his admission into the hospital. The blow was 
received on the right side of the head, at the anterior inferior part of 
the OS frontis, immediately over the orbit of the eye; was insensible 
for a few minutes after the accident; had no vomiting. When ad- 
mitted, pulse was feeble and frequent; skin cool; rationality good; 
has a cut four and a half inches in length in scalp, which is turned 
off, exposing a considerable portion of the cranium, partly denuded 
of periosteum; a fracture by which the upper part of the orbit was 
forced down over the eye; a small, loose fragment was removed; there 
is also a cut half an inch long at external canthus, from which there 
is slight haemorrhage; eye uninjured. The depressed portion of bone 
was elevated to nearly its natural position, and light dressings ap- 
plied; patient complained of no pain, and rested well during the night, 

24/A. Without pain; pulse slow and regular, rather weak; tempera- 



Kirkbride's Cases treated in the Pennsylvania Hospital. 67 

ture of surface natural 5 pupil not contracted; purge with magnes. 
sulph.i low diet. 

9.5th, 8 d. M. Complains of chilliness; pulse feeble; pupil natural; 
medicine taken yesterday has not operated; increased restlessness. 
Repeat magnes. sulph.; hot applications to extremities. 7 P.M. 
Patient suddenly became convulsed and comatose at I5 P. M.; pulse 
full and frequent; pupil nearly natural; strong flexion of arm on un- 
injured side during the attack. He was bled ^xx., and had cups ap- 
plied to back of head, after which became sensible. At this time 
very restless; inclined to sleep; articulation indistinct; easily roused; 
pupils slightly dilated; left eye drawn strongly to internal canthus; 
resistance to efforts of extension of arms, but doubtful whether vo- 
luntary or involuntary; pulse frequent and weak; skin warm; bowels 
have been freely open. R. Ant. tart. gr. j.; Aquae, §vj. Ft. sol. S. 
^ss. every hour; stimulating pediluvia. 11 P. M. Worse; pulse 
feeble, frequent, and irregular; restless; tossing about the bed; says 
he has no pain; respiration slightly stertorous; left eye fixed at in- 
ternal canthus; right in natural position; answers questions, but not 
distinctly. Ordered cups to head; sinapisms to legs; continue sol. 
ant. tart. 

£6^A, 9 Jl. M. Low, muttering delirium; increased restlessness; 
eyes as last reported, with more dilatation of pupil, and complete in- 
sensibility to light; surface of body, natural temperature. The sepa- 
rated fragments of bone were this morning removed, requiring only 
detachment from a small portion of scalp. Cold applications to head, 
and heat to extremities; respiration became more laborious; extre- 
mities cold; pulse imperceptible. Death at 4 P. M. 

Autopsy^ fifteenhours after death. — Exterior. Rigidity marked; fine 
muscular development; tumefaction of right wrist; irregular ecchymo- 
sis and tumefaction of right side of face; wound four and a half inches 
long, extending from near internal canthus, upwards and outwards; 
flap raised, exposing frontal bone for a distance of three inches; rough 
edge of bone extending from inner part of orbitar ridge, half an inch 
upwards and one inch outward, and thence along middle of orbitar 
plate, including space from which bone was removed, filled up with 
dark coagulum of blood. 

Head. Dura mater opposite the seat of fracture, covered with a 
thick layer of dark coagulated blood, adhering strongly to the mem- 
brane, in the midst of which are two perforations, largest would admit 
a crow-quill; sinus empty. Dura mater much injected externally. 
Arachn.oid, bright injection on side next to dura mater; great cavity 
contains a purulent cream-like liquid, easily removed by scraping, 



68 Kirkbride's Cases treated in the Pennsylvania Hospital. 

and beneath arachnoid the anfractuosities are filled with the same 
liquid, which may have furnished that in great cavity. Pia mater, 
bright injection at anterior part and opposite temporal bone; large 
veins distended with blood. Arachnoid of dura mater, dull colour, 
semi-opaque; great cavity of arachnoid contains posteriorly about 
§ss. of dark fluid blood. Cortical substance of right side, dark 
reddish colour; medullary much injected, consistence perfect. On 
anterior extremity in part corresponding to fracture, are three ecchy- 
moses, largest size of a large pea, not extending beyond cortical sub- 
stance, which is softened in ecchymosed part; beneath these ecchy- 
moses is another in medullary part, a little larger than the others, 
with similar diminution of consistence; adjoining parts, as elsewhere, 
firm, but much injected; ventricles contain §ss. of limpid serosity; 
central parts firm, not injected. On left side, cavity of arachnoid 
contains a little serum, no pus; moderate injection of pia mater; cor- 
tical substance, firm, ash colour; medullary much less injected than 
on right side; cerebellum firm, slightly injected. 

Thorax. Strong adhesions on right side, less on left; lungs 
grayish, dotted with black; no trace of emphysema; no tubercles. 
Lower lobe of right more engorged than rest, friable; two calcareous, 
soft concretions near root of lower lobe, encysted. Bronchi not in- 
jected, polished, not dilated. Heart, medium size, pale, flaccid; 
coagulum in each cavity fibrinous; slight cartilaginous concretions in 
semilunar valves of aorta; some cartilaginous patches beneath lining 
membrane of aorta at the arch. 

Ahdomen.' — Stomach. Contains half a pint of greenish and grumous 
liquid; great cul-de-sac torn in detaching it from spleen; mucous mem- 
brane scarcely exists in whole posterior face, especially of great cul- 
de-sac; other coats of consistence of half coagulated glue; transpa- 
rent appearance. Anterior face, pale, dirty-yellow; consistence na- 
tural. — Small intestines contain some yellowish mucus; mucous mem- 
brane transparent; good consistence; less near extremity of ileum. 
Glands of Peyer reticulated, pale, a little elevated. Isolated follicles 
numerous in last two feet, but scarcely visible; mesenteric glands 
firm. — Large intestine empty; mucous membrane, pale, consistent. — 
Spleen reddish-brown,' seven inches by four; soft, grumous. — Liver 
pale brown, larger than natural; no tubercles; gall-bladder distend- 
ed. — Kidneys rather pale, firm, not granulated. 

Case IV. Fracture of the Skull, Sfc. — Stephen James, aet. 50, a 
respectable coloured man, residing in the lower part of the city, was 
severely injured during the riot on 13th of August, 1834, about 10 P. 
M. He was dragged from his bed into an adjoining yard, beaten and 



Kirkbride's Cases treated in the Pennsylvania Hospital. 69 

left in a state of insensibility — owing to the state of alarm in his family 
he received no medical assistance until the following morning; he was 
reported to have lost a large quantity of blood during the night; had 
vomiting in morning; some blood in discharges from stomach. He is 
robust, temperate in his habits, and has always enjoyed good health. 

lAth, Admitted into the hospital at 7 A. M. He has several in- 
cisions on head, principally on superior and posterior part, extend- 
ing down to and exposing a portion of cranium denuded of perios- 
teum; parts are much swollen; no fracture or depression detected. 
Skin is cool and moist; pulse 124, feeble; pupils natural, with little 
sensibility to light; has not spoken since he was injured. Sinapisms 
to extremities; stimulating enema; and heat to surface generally. 
10 A. M. Respiration slightly stertorous; pupils natural; pulse 120, 
feeble; restless; constant moaning; no vomiting. 1P.M. Stertorous 
breathing increased; pulse 112, rather fuller, with an occasional in- 
termission; skin warmer; more sensibility of pupil, a little contract- 
ed; some subsultus; restraint necessary to keep him in bed; has not 
been able to swallow since admission. 7 P. M. Skin hot; pulse 140, 
still feeble; no rigidity of extremities; swallows small portions of li- 
quid with extreme difficulty; pupils a little dilated, do not contract 
when exposed to a strong light; respiration stertorous; tossing of the 
arms; no subsultus. 

15/A, 8 ^. M. Very restless during the night; bowels freely open 
after enema last evening; appears to recognise his friends, but is 
unable to speak; no improvement in deglutition; pulse 136, some irre- 
gularity; skin warm; coughs occasionally, and discharges some bloody 
pupils nearly natural; less stertor. 

16/A. More quiet during the night; pulse is irregular and inter- 
mittent; pupils slightly contracted; strabismus; is able to swallow 
liquids. 

17^^. Very restless; no sleep; skin cool; pulse feeble and irregulari 
strabismus slight; deglutition improved. 

20^^. Since last report there has been some re'action, and he now 
swallows with little difficulty; speaks, but indistinctly; pulse fuller^ 
pupils natural. 

22c?. Pulse again feeble; skin cool; restless; no rigidity; slight con- 
traction of pupils. 

23rf. Pulse 132, very weak; skin cool; pupils more strongly con- 
tracted; restless; tossing his arms; can scarce articulate; during ef- 
forts to speak the mouth is drawn strongly to the right side. 

SlAth. Pulse 140, irregular, excessively weak; extremities cold; in- 
ability to speak or swallow; rigidity of both arms and both legs, 



70 Kirkbride's Cases treated in the Pennsylvania Hospital. 

nearly equal; slight distortion of mouth, variable. Death at 11 
P. M. 

Autopsy, 10 hours after death.^Exierior. Rigidity complete; slight 
emaciation; cuticle removed on legs and chest by sinapisms. 

Head. On exterior, scalp offers at top of forehead, two whitish lines 
an inch long, one of which is easily separated by the finger, (cica- 
trices of two of the wounds;) on cranium are eight other incisions not 
united, from one to two inches in length; three of these incisions 
unite near the summit of occiput; another of them about two inches 
long is in the long diameter of skull on right temporal bone. The 
periosteum is detached beneath one of the incisions on summit of fron- 
tal bone, near middle line, in length of one inch and a few lines 
broad. Cellular tissue on whole ecchymosed and tumefied. On re- 
moving periosteum no depression discovered, but a long fissure, ex- 
tending in a curved line from one temporal bone to the other. Upon 
removing the cranium a deposit of blood an inch and a half in dia- 
meter, and more than a line thick, was visible near the base of squa- 
mous portion of temporal bone; a line was traced by this same de- 
posit on the outer surface of dura mater, irregular, but in most places 
several lines wide to the left side, where another deposit of blood, a 
little less than that on right, and anterior to it was found; dura mater 
not cut; fracture extended through both tables of the skull, which was 
of moderate thickness. Jlrachnoid containing about ^iij. limpid se- 
rum, part of which escaped on sawing the skull; pia mater infiltra- 
ted witli serum, which caused an apparent thickness of the mem- 
branes, removed by pressing out the liquid; glands of Pacchioni very 
distinct, large as wheat grains. Beneath each temporal bone in spot 
corresponding to coagulum, exterior to dura mater, is a collection of 
black blood in the meshes of pia mater between the convolutions, 
larger in the right than left; on detaching the pia mater on right side, 
the finger passed into a softened portion of the brain; this softening 
contained in its centre a black coagulum, half an inch in diameter, 
surrounded by cerebral substance, reddish, and reduced to a pulpy 
state, with flakes of brain, but not distinct pus; the medullary sub- 
stance surrounded by it was injected, of a slightly yellowish tinge; 
no trace of false membrane around this softening, which is circum- 
scribed by the firm, cerebral substance. On the left side a coagulum 
and softening precisely similar to that on right, except that the left 
was not larger than a nutmeg, while that on the right was larger than 
a pigeon's egg. Substance of brain elsewhere firm. Ventricles con- 
taining ^ij. limpid serosity; choroid plexus pale. Base of brain con- 
tained iiv. of serum; substance at base, cerebellum and pons firm; 



Kirkbrlde's Cases treated in the Pennsylvania Hospital. 71 

moderate injection; longitudinal sinus empty; lateral containing 
liquid blood. — Medulla spinalis. Abundant serosity in arachnoid; 
substance firm, not injected. 

Thorax. — Bight lung. No adhesions except at posterior part of in- 
ferior lobe, which is covered with a layer of yellow, concrete lymph, 
one line thick, easily detached in long strips. At summit of lung are 
several tuberculous masses, size of large pea to that of hazelnut, soft- 
ened, contained in cartilaginous cysts; gray granulations around 
these masses; in middle lobe are also a few scattered tubercles, size 
of a large pea, softened; none in lower lobe, which is aerated; vesi- 
cles not evidently enlarged; bronchia pale. — Left lung. No tuber- 
cles nor granulations; slight adhesions anteriorly; bronchi pale. — » 
Heart. Moderate size; large coagulum in right ventricle; valves 
healthy; little serosity. 

Jibdomen.--^ Stomach contracted; mucous membrane dark slate co- 
lour, less intense in great cul-de-sac than elsewhere; moderately fine 
arborizations along small curvature. In great curvature are two round- 
ed ulcerations, largest four lines in diameter, smallest two, pale, ele- 
vated edges, gray cellular bottom; consistence of membrane good.— 
Small intestines containing a greenish-yellow mucus; membrane in 
upper three-fourths very pale slate colour, not injected, firm. Glands 
of Peyer rare, pale, reticulated, only seen near the valve. Glands 
of Brunner rather numerous in last foot; no central point. — Mesen- 
teric glands small, gray. — Large intestine in coecum; membrane 
grayish, thin, strips fragile, three or four lines; rest of extent, mem- 
brane grayish, strips eight to twelve lines; contents liquid; glands 
not visible. — Liver. Dark brown, not broken, gorged with blood; a 
hard, whitish, rounded mass near the sharp edge without defined 
cyst; indistinct fibres, creaking under the scalpel; bile abundant.-— 
Spleen. Very small; wrinkled two and a half inches by two; not tu- 
berculous. Kidneys brown colour; firm. 

For notes of the following case I am indebted to my friend and 
colleague, Dr. Gerhard. 

Case V. Phrenitis, following an Injury of the Head. — John Gal- 
lagher, a child, twelve years old, was playing on the roof of a three- 
storied house, from which he fell, on the afternoon of the 10th of Au- 
gust, 1834. At his entrance into the hospital, had a large ecchymosis 
with tumefaction of the eyelids of the right eye and parts covering 
the malar bone and temporal fossa; a fracture existed in both bones 
of both forearms about two inches from the wrist. Intellect clear, 
but much agitation, and complains of pain in the arms, which were 
dressed by the application of splints and compress. Until 15thj slight 



72 Kirkbride's Cases treated in the Pennsylvania Hospital* 

increase of pulse and heat of skin; great restlessness; complains of 
pain in arms, constantly throwing them about; intelligence perfect, 
but very irritable, and great sensibility to impressions. 

On 15th, after sleeping quietly, (fths gr. of morphia having been given 
during preceding day,) had great increase of heat, no chill remarked, 
but extreme stupor, lying without the least attention to surrounding 
impressions. At 8 P. M. found him in the following state: decubitus 
dorsal; eyes closed; arms lying by his side, not much tossing about; 
skin intensely hot; face flushed; pupils much and equally dilated, 
little contraction on exposure to light; sensibility generally augment- 
ed; cries on moving the limbs; sight appears nearly perfect; hearing 
good; quickly relapses into the state of stupor when aroused; pulse 
140, quick, regular; respiration regular, 28 to 30; no cough; consti- 
pation. R. Iced water to head; Pulv. seidlitz. No. ij. 

iQth, Very restless during night; frequent cries as if in pain, al- 
ternating with stupor; some dilatation of pupils, and increase of sen- 
sibility; pulse 140, quick; head strongly bent backwards, cries if at- 
tempts are made to replace it; thirst great; no requests /or /ooc/y face 
flushed; no rigidity; violent delirium, or during night cries; gives in- 
telligible answers to questions if loud, and then relapses into a state 
of coma. V. S. §xviij. After bleeding face pale; less violent deli- 
rium; pulse much more feeble. 

In evening pulse less feeble than in morning; some delirium; skin 
again hot. Twenty leeches behind ears; blister over scalp. 

During the three days, 17th, 18th, and 19th, the following symp- 
toms were observed. Delirium, quick, irregular, and noisy, with 
sometimes cries. On IQth, coma; pupils dilated during whole attack; 
not sensible to light on* 18th or 19th. Strabismus 17th, 18th, and 
19th. The inclination of the head backwards increased in strength, 
but there was no evident rigidity of the limbs; no distortion of the 
features, unless slightly puffing of the mouth; countenance anxious, 
flushed; no replies to questions after 18th; constipation relieved by 
enemata or Seidlitz powders; no vomiting. Deglutition impossible 
after 18th; meteorism of abdomen on 18th and 19th. Complained of 
pain in belly on 18th; pulse regular, very frequent, from 120 to 180. 

Death 20th, at 9 A. M. 

Autopsy^ eight hours after death. — Dura mater distended; long 
coagulum in sinus; fracture with depression of both tables of os frontis 
on right side, just above the external angle of orbit; fracture extends 
through the orbitar plate in its whole breadth; just above this frac- 
ture the dura mater is torn, and a coagulum of black blood an inch 
in breadth exists. Summit of convolutions compressed; arachnoid 



Kirkbride's Cases treated in the Pennsylvania Hospital. 73 

drj; no serosity in pia mater, which is highly injected in its small 
vessels only; on the left side the pia mater presents a number of yel- 
lowish spots in the line of the vessels, not broader than from one to 
one and a half lines, and detached with the membrane; cortical sub- 
stance gray-rosy; medullary moderately injected; consistence per- 
fect; ventricles distended with about ^iv. of troubled serosity; cen- 
tral parts diffluent; walls of ventricles softened to creamy consistence 
in a depth of from one and a half to three lines, white, surrounding 
injection; choroid plexus pale. — Base. A layer of greenish-yellow 
lymph, from three-fourths to one and a half lines in thickness, cover- 
ed the pons, the optic and olfactory nerves, the medulla oblongata, 
the fissures of Sylvius, and the lateral fissures, extending through 
the fissures of Sylvius to the upper part of the hemisphere, and ex- 
isting in a slight degree on the inferior surface of the cerebellum. 
This substance was beneath the arachnoid, which has a glutinous 
feel, and contains hardly ^ss. of serosity. The substance had the 
following characters: inodorous, greenish-yellow, rather more con- 
sistence than pus, but easily broken by slight pressure without trace 
of granulations or other hard bodies. The cerebral substance of the 
base was of the natural consistence, except just below the substance 
described, where it was whitish and pulpy. Pons varolii and cerebel- 
lum firm. 

Liver not fractured; gorged with blood; firm. 

Other organs not examined. 

Case VI. Wound of the Elbow-joint ivith Injured Spine.— Thonms 
Paul, set. 24, seaman; admitted April 26th, 1834. Is remarkably ro- 
bust; has enjoyed good health, never had serious disease; clear of 
cough, &c. ; lives freely. A short time previous to admission, fell 
from the foretop of a vessel, striking his arm upon a windlass, and 
producing a lacerated wound, communicating with the elbow-joint; a 
wound of scalp, two and a half inches long, and exposing a small 
portion of cranium and a severe contusion over the lumbar vertebra. 
He was insensible for a few minutes, but when he entered the hos- 
pital, had recovered entirely from that state; his pulse was 88, regu- 
lar; skin natural; sensibility perfect; moved his extremities without 
difficulty. His arm was placed on a rectangular splint, with simple 
dressings to it and head. 

9,7th. Has some fever; restlessness during the night, tongue white 
and furred, bowels not opened; suffers much pain. Ordered eight cups 
to loins; Magnes. sulph. §j.; Mist, neutral, jss. every two hours; 
low diet. 

28th. Less pain, but does not appear to move his lower extremi- 

No. XXIX.— November, 1834. 7 



74 Kirkbride's Cases treated in the Pennsylvania Hospital. 

ties with the same facility as yesterday; wound of elbow very pain- 
ful; fever moderate; bowels freely open. Repeat cups to spine; poul- 
tice to arm. 

9.^th, Sickness of stomach; swelling of arm, and indications of ery- 
sipelas; complains that he '^ cannot feel his legs," and is utterly un- 
able to move them. Mist, etferves. ; 50 leeches to arm. 

30/A. Paralysis of lower extremities complete; moves the uninjured 
arm, but to-day for the first time has complained of a numbness about 
it, and of its being '« cramped;" inflammation about the joint un- 
abated; less vomiting; head-ache. Treatment continued. 

May 1st. — Was called to patient very early this morning; during 
the night his respiration had become seriously affected; when I saw 
him was panting and complaining that he " had no breath;" exceed- 
ingly anxious countenance; scarce able to articulate; pulse feeble and 
frequent; skin cool, covered with perspiration. Sinapisms were di- 
rected, and heat applied externally, but without effect; pulse gra- 
dually became imperceptible; body cold, bathed with perspiration: 
respiration more laborious. Death, 9 A. M. 

»8.ntopsy^ twenty-six hours after death. — Exterior. Fine muscular 
development; ecchymosis of back; rigidity of lower extremities. 

Head. Much blood on exterior of dura mater; longitudinal sinus 
full of half-coagulated blood; pia mater rather injected; large veins 
slightly distended. Arachnoid moist; no infiltration; easily detached. 
Glands of Pacchioni small. Cortical substance gray-ash; medullary 
rather more injected than usual, firm; central parts firm, white. Ven- 
tricles containing §ss. of serum. Cerebellum firm, moderately in- 
jected. 

Spine. Muscles opposite lower dorsal and lumbar vertebrae soften- 
ed; fibres scarcely perceptible, infiltrated with blood and purulent 
liquid; no fracture of processes. On exterior of dura mater is a layer 
of half-coagulated dark blood, extending throughout all the dorsal 
and lumbar vertebrae. Arachnoid containing a moderate quantity of 
serum; pia mater slightly injected. Consistence of medulla good, ex- 
cept about lower part of dorsal vertebrae, in extent of one and a half 
inches, and in the last inch, where the medullary portion is a little 
yellowish, and rather less consistent than elsewhere. 

Thorax. No adhesions; pleura contains §j. of serosity. — Lungs 
gorged with blood, especially lower lobes; dark red externally and 
internally; no trace of hepatization or tubercles. Bronchi transpa- 
rent, containing a little serum; bronchial glands firm, dark. — Heart. 
Not adherent, firm,; medium size; aorta filled with blood, of dark vi- 
nous colour. r^' 



Kirkbride's Cases treated in the Pennsylvania Hospital. 75 

Abdomen. — Stomach. Containing ^ij. of greenish liquid of acid 
odour; mucous membrane of light slate colour, especially in pyloric 
half; some large arborizations near cardia; in posterior half of great 
cul-de-sac thickness a little diminished, (with paleness,) in irregular 
spots, and general diminution of consistence of all the coats; else- 
where consistence natural. — Z^woofmwm grayish, not injected. — Small 
intestine not distended; contains a yellowish liquid; slate colour or 
pale externally; mucous membrane without the least injection, 
throughout of a pale or light slate colour, very faintly tinged in spots 
by the contents; consistence throughout natural. Glands of Peyer 
very apparent, very slightly elevated; isolated follicles visible, (size 
of millet-seed,) in last foot or two many with little central points. — 
Mesenteric glands firm, grayish, good size; one size of hazelnut, en- 
cj^sted and converted into a hard calcareous substance. — Large in- 
testine contains a little liquid faeces; not distended; mucous mem- 
brane pale. — Liver large; containing much blood; adhesion one and 
a half inches square to diaphragm; firm; two substances not very dis- 
tinct. Gall-bladder much distended by thick, viscid hW^.^- Spleen 
six inches long, soft, but texture preserved. — Kidneys firm; smooth 
externally; reddish-brown; membrane easily detached. — Bladder 
small; containing dark-coloured urine; mucous membrane pale. 

Case VII. Abscess of the Lungs, 4'C. after Amputation. — Charles 
Thompson, set. 34, seaman, admitted April 19th, 1834. He states 
that when at sea, three weeks before his admission, he fell a consi- 
derable distance, and received an injury of the right knee; was quiet 
only a few days, and then commenced walking; that inflammation 
immediately came on, and has continued to increase; has suffered 
immensely with pain and constitutional symptoms; has never been 
very robust; is of an irritable temperament, and has lost a great deal 
of flesh since the occurrence of the accident. 

When first admitted, knee was very much swollen; great heat 
and tenderness of every part; an ulcerated surface on its inner side 
half an inch in diameter, from which there is a very copious dis- 
charge of a yellowish serous fluid, interspersed with flakes of lymph, 
evidently from the cavity of the joint; has a quick, frequent pulse; 
anxious countenance; bad appetite; night sweats; sleeps badly; bowels 
irregular. 

His limb was elevated on an inclined plane; leeches freely and fre- 
quently applied, with cold mucilages, and afterwards emollient poul- 
tices; his strength supported by a mild nutritious diet and tonics j 
under this treatment, the swelling and heat of knee diminished; the 



76 Kirkbride's Cases treated in the Pennsylvania Hospital. 

discharge, however, became more purulent in appearance, and in- 
creased so much in quantity that upwards of a pint was frequently 
discharged at a single dressing; the hectic became more decided; 
emaciation increased, and his sufferings were so great, that after con- 
sultation, it was determined to amputate the limb, as offering the 
only chance for the preservation of his life. 

The operation was performed by Dr. Harris, on the 14th of May, 
at 11 A. M. a few inches above the knee. Patient bore the operation 
well. Upon examining the knee-joint, it was found filled with puru- 
lent fluid; synovial membrane no where apparent; cartilages almost 
destroyed. — Evening. Pulse is ISO, less frequent, and fuller than 
before the operation; skin moist and warm; suffers but little pain; in 
fine spirits. 

15th. Doing well; little pain; slight spasms of the stump; pulse 
112; tongue moist. Allowed chicken water in addition to gruel. 

\7th. Stump dressed this morning; looks well; a portion has 
united by adhesive inflammation; healthy suppuration commencing; 
rests well at night; bowels open yesterday. Diet increased. 

19/A. Did not rest well last night; had a chill in the evening; pulse 
quickened this morning; stump looks well; tongue moist; moderate 
discharge from an abscess of the thigh. 

Sllst. Larger discharge than usual from abscess; little change in 
symptoms generally; appetite not very good; has full diet. 

22d Less discharge; had another chill this morning; pulse weak, 
150; says he " feels well;" countenance pallid; had flushes of heat; 
tongue moist. In the evening had an attack of colic. 

23c?, Morning. Pulse 160; unusual restlessness and anxiety. At 
10 A. M. a chill followed by fever and sweat. — Evening. More 
comfortable; bowels opened by enema; pulse 140, weak; skin moist, 
rather below the natural temperature. Wine in addition to diet. 

24/^. Very ill; another chill last night; pulse exceedingly frequent; 
complains of a sense of chilliness, although his surface is of natural 
temperature; has constant tremors; tongue moist; no tenderness de- 
tected on pressing any part of abdomen; respiration hurried; consi- 
derable anxiety and contracted appearance of the countenance. Has 
been taking Quin. sulph. gr. j. every two hours. Pulse, (8 P. M.) 
rather fuller, and less frequent; the quantity of pus has diminished, 
but to-day there was some bloody serum discharged from stump. 

26/^. Little change, and no improvement since last report; dis- 
charge darker, but not increased in quantity; tongue moist; pulse 
very frequent and feeble. Treatment continued. 



Kirkbride^s Cases treated in the Pennsylvania Hospital 77 

27//i. No chill yesterday, but had feverj slight chilliness this 
morning; no appetite; tongue moist; pulse at evening less frequent. 
Same treatment. 

28//i. Respiration still short and hurried; pulse as last reported; 
tongue moist; sweats less than for several days past; intelligence 
duller, and occasional delirium; discharge from stump small, and of 
bad aspect. Treatment continued. 

29//i. Respiration more laborious; pulse can scarce be felt at the 
wrist; has had tendency to diarrhcKa; very restless during the night. 
Died at 9^ A. M. 

*.iutopsy^ twenty-five hours after death. — Exterior. Emaciation; ri- 
gidity of extremities, particularly the upper; no lividity. — Stump. 
Union had taken place in about two-thirds of its extent, leaving the 
middle portion where the bone protruded a little. Cutaneous flap 
adhered closely; union could be broken up by using considerable 
force, leaving drops of blood in corresponding points of the two sur- 
faces; no pus or other substance between these flaps; at the inferior 
part is an abscess an inch in depth, containing a small quantity of 
pus, covered by a false membrane, of thickness of fine parchment- 
The arteries obliterated to the extent of near two inches, and con- 
taining dark coagulum above this point, which adhered closely to the 
sides of the vessels; up to groin internal coat yellowish, and all the 
tunics increased in thickness. — -Veins^ (traced as arteries from above 
downwards,) containing in upper part dark, grumous blood; obliter- 
ated by a firm, dark coagulum in lower two inches; one vein, lead- 
ing from external part of hip, contains a mixture of dark, clotted 
blood and purulent liquid; coats yellowish, slightly thickened, like 
those of the others; in tracing this last vein is found an abscess, 
which communicates with the cavity of the hip-joint, extending three 
inches below the trochanter on external side of bone, which is in 
that space denuded of periosteum in extent of two inches, and around 
two-thirds of its shaft; the muscles and cellular substance around it 
infiltrated with purulent fluid; false membrane not distinct; joint 
opened above and externally; articular cartilages not affected; syno- 
vial membrane not injected; lymphatic glands of that groin size of 
almonds, double that of left; rather soft; no pus. — Sciatic nerve^ ad- 
hering to skin of stump by button-shaped extremity larger than the 
rest of nerve; same dots on its extremity as elsewhere. 

Head. Dura mater, quantity of blood externally very small; longi- 
tudinal sinus empty; serosity in arachnoid moderate; pia mater pale. 
Cortical substance pale-gray; medullary less injected than usual; con- 
sistence of both perfect. Central parts pale, firm. Ventricles con- 



78 Kirkbride's Cases treated in the Pennsylvania Hospital, 

taining §ss. of serum; plexus pale. Cerebrum pale, firm. — Spinal 
marrow pale and firm; no serosity in arachnoid. 

Thorax. Left pleura containing upwards of a pint of purulent se- 
rosity, with flakes of coagulable lymph floating in it; lung in corres- 
ponding part of thoracic parietes covered by a thin, pultaceous false 
membrane, one-fourth of a line thick, easily detached; the pleura 
below it thickly dotted with red. Upon removing the false mem- 
brane, on the surface of the lung, a number of yellowish spots, from 
one to three lines in diameter, appear below the pleura. Upon re- 
moving the pleura the spots were seen to be formed of small collec- 
tions of yellow, homogeneous pus, from the size of a small pea up to 
that of a large one; in the largest a thin, whitish membrane was 
found, not perceptible in smaller. These purulent collections were 
more numerous in lower than upper lobe, and much nearer the sur- 
face than centre of the lung, where two or three only were found. 
Bronchi pale; vessels empty; no appearance of pus, at least in the 
ramifications that could be traced. Tissue around the abscesses 
aerated: some places a little darker, but not hardened; the posterior 
half of the upper lobe heavy, still containing air, resisting pressure, 
friable, containing much serosity, (commencement of induration;) 
lower lobe containing less serosity, not indurated. — Bight lung. 
This pleura contained §viij. of purulent serosity; same false mem- 
brane covering posterior part of lung; purulent collections equally 
abundant as in left, of same size, and found beneath the pleura, and 
some in the centre of the parenchyma; same anatomical appearances; 
posterior half of the upper lobe indurated partially, as in the left; 
still containing much serosity and some air. Bronchi not thickened, 
pale; bronchial glands small; in neither lung, any traces of granula- 
tions or tubercles. — Heart. Moderate size, flabby; membrane pale; 
coagulum on right side; valves healthy; §ss. of serum in pericardium. 

Abdomen. Stomach distended, containing a thin, yellowish liquid; 
cardiac half, posterior part, pale and milky; exact line of demarcation 
between it and the pyloric half. In cardiac portion, numerous sub- 
cutaneous bluish vessels; mucous membrane softened, nearly gelati- 
nous; other coats rather thickened, not evidently softened; pyloric 
half, pale slate colour covered with thick mucous, slightly mammillated 
along great curvature; strips, natural length, six to eight lines; an- 
terior face of cardiac half, pale, not milky, without evident line of de- 
marcation; strips rather friable, thin, three to four lines; pyloric half 
nearly as in posterior face. — Small intestines. Tunics thin, containing 
a yellowish mucus; mucous membrane throughout pale, thin every 
where, especially towards the valve, strips six to seven lines, not in- 



Kirkbride's Cases treated in the Pennsylvania Hospital 79 

creased towards its termination 5 glands of Peyer pale, reticulated, 
very little prominent^ isolated glands not visible^ mesenteric glands 
small. — Large intestines containing a small portion of hardened 
fseces; mucous membrane pale, consistence good. — Liver moderate 
size, brick-red, mottled with bluish spots externally^ interior same 
red, interspersed with nuclei of dark brown, or in one or two in- 
stances of lighter red, than the rest of the texture 5 upon scraping 
these masses, they may be detached from the rest of the tissue, from 
their pulpy consistence, no distinct membrane around themj in centre 
of one or two, a yellowish spot, apparently pus, was observed, con- 
sistence generally good; bile abundant, greenish. — Spleen seven 
inches long, soft, dark, pulpy. — Kidneys smooth externally, ^rm; 
bladder contracted. 

Case VIII. Phlebitis following the Operation for Varicose Veins. — 
John Farrell, set. 30, workman in a chemical laboratory, was the 
third in a series of operations for varicose veins, performed by Dr. 
Harris in the spring of 1834, and the only one attended by any un- 
pleasant symptoms. The operation consisted in the removal of about 
three-fourths of an inch of the diseased vein, from the part that passes 
along the inner side of the knee. 

He was admitted into the hospital on the 19th of April, having an 
ulcer on the right leg originally caused by an injury received about 
nine years ago. The ulcer has been frequently healed, but generally 
remained so but for a short time. The veins on that leg are distend- 
ed, thickened and tortuous, from near the ankle to within a few 
inches of the groin; general health good. Operation performed on 27th 1 
compress placed on upper and lower end of divided vein, and a tight 
roller applied from the foot up to the groin. 

Patient did well till SOth, when he complained of pain about the 
knee, around which is some erysipelatous inflammation. A red line 
is also observed to extend upwards in the course of vein to within an 
inch or two of the groin, with evident thickening and tenderness on 
making pressure upon the part. Pulse 100, intermits every fifth 
beat; countenance anxious; tongue whitish; bowels not open. Order- 
ed fifty leeches along the vein; purge with magnes. sulph.; cold mu- 
cilage to knee. 

May 1st. Inflammation of vein has increased but little; patient has 
some fever; pulse 100, with fewer intermissions; bowels freely purg- 
ed by medicine yesterday; erysipelas extending; patient much de- 
pressed; fifty leeches along vein, followed by emplast. vesicat. ; mist 
neutral, ^ss. q. 2. h. 

2f/. Blister drew well; erysipelas still extending upwards; patient 



so Fosgate on Nightmare. 

expresses himself as feeling more comfortable; skin less hot; pulse 
90, without intermissions. Treatment continued. 

Sd. Better; pulse 92, soft, regular; skin warm; tongue cleaning; 
swelling and tenderness along course of vein diminished; rested well 
last night; less anxiety of countenance; slight extension of erysipelas. 
Same treatment. 

5th. Nearly as last reported. 

7th. Still some anxiety of countenance; swelling and tenderness 
along vein has nearly disappeared; erysipelas extended almost to 
groin, with increase of pain; pulse is feeble, and has occasional inter- 
missions; tongue inclined to dryness; bowels open; muscular weak- 
ness considerable. Substitute linam. saponis. for mucilage; let him 
take quin. sulph. gr. ss. q. 2. h. 

Sth. Had a tolerable night; spirits still depressed; pulse fuller, soft, 
without intermission; less dryness of tongue; no extension of erysi- 
pelas. Remedies continued. 

9th. Slight improvement; pulse 90, fuller and regular; great swel- 
ling in leg; slight return of appetite. Continue tonic; increase diet. 

llth. Doing well; anxiety of countenance gone; pulse 80; tongue 
clean and moist; appetite good; sleeps well. 

13//2. No tenderness whatever in course of vein; slight swelling 
and redness continue in leg. 

lAth. Swelling subsiding rapidly; pulse slow and soft; bowels re- 
gular; good appetite. 

iWi. Ulcer on leg healed some days since; after subsidence of 
tenderness the roller was resumed on leg; has full diet; walks a little. 

The patient continued to improve daily from the date of the last 
report, he gained flesh and strength, and was discharged well, June 
1st. 



Art. IV. Observations on Nightmare. By Blanchard Fosgate, 
M. D. of Auburn, N.'y. 

JS IGHTMARE and incubus are terms applied to a disease, deeply 
interesting both to the physician and to the patient. To the physician, 
because no satisfactory explanation of its phenomena has been given, 
all being mere speculation not founded on facts, neither supported by 
correct pathological reasoning: and to the suflferer, for it seizes him 
under circumstances frightful in themselves, occurring mostly at dead 



Fosgate on Nightmare. 81 

of night when assistance is least easily obtained, and he being render- 
ed totally helpless. 

It makes its attack on the system in that stage of sleep when the 
voluntary power is suspended, and the imagination is free from those 
restraints imposed upon it in the state of wakefulness by our judg- 
ment. The mind roving through various scenes and producing ef- 
fects, only experienced in dreams, and best described by reference 
to them, arrives at a condition in which fear is the most prominent 
emotion. The dreamer often believing himself shipwrecked, and left 
to the mercy of the winds and waves; or he is fast approaching the 
brink of an awful precipice, without the power to turn aside, and over 
which he must unavoidably fall; or he is pursued by wild beasts in- 
tent on devouring him, and through all he feels spell-bound and unable 
to help or defend himself: he struggles with all his power to be re- 
leased from this frightful situation, but apparently to no purpose, 
until at last when he considers his destruction inevitable, a sudden 
bound frees him from his condition, and a dream is disclosed, which 
he believes to have been the cause of his suffering. 

The eflfects produced on the system are very great. Immediately 
after recovery the pulse is a little quickened, a tremor of the abdo- 
minal muscles is experienced, and extreme lassitude is felt throughout 
the whole frame. A want of energy characterizes this state; and 
as the first shades of sleep again descend upon him, he very percep- 
tibly feels the approach of the disease a second time, but under dif- 
ferent circumstances. From a lack of energy to change his position 
and shake off the predisposition now formed, he remains quiet, per- 
fectly conscious of the advancing symptoms which are gradually 
stealing over and strengthening upon him, until the power of volun- 
tary motion is again suspended, and he is in a condition differing 
from the first, inasmuch as he is conscious of his situation. He now 
attempts to change his position, but without success, and it is only 
after repeated trials that he succeeds in accomplishing his object. The 
same lassitude continues as after the first attack, and the second will 
be followed by a third with the same symptoms, and the third by a 
fourth, and so on until his exertions are sufficient to throw off the 
disease, by producing an action throughout the whole voluntary mus- 
cular texture. 

There is no particular position necessary for the occurrence of this 
disease. It makes its attack in any position that a person can lie, 
and the setting position is not exempt from its effects. 

This disease may be divided into the first and second paroxysms. 



82 Fosgate on Nightmare. 

or that which is accompanied bj a dream, and the succeeding attacks 
in which consciousness is present. 

In addition to the feelings described in the first paroxysm, there 
is the sensation of a load upon the chest, and some fancy it a monster 
attempting to suffocate them. From this paroxysm very little infor- 
mation can be obtained, the person on awaking attributes all his suf- 
ferings to the dream which he considers the cause of his distress. 

It is by attending strictly to the phenomena of the succeeding at- 
tacks that a knowledge of the pathology of the disease can be obtain- 
ed. In these attacks many faculties of the mind are active and res- 
trained to their proper course by the judgment. This is displayed 
in the exertion to move one part of the body and then another alter- 
nately, knowing if we succeed relief will be obtained. Neither is the 
memory dormant, for when we have been told that some of the senses 
are not impaired, and that we can exercise certain muscles, we are 
sure to make the trial. A person labouring under the second pa- 
roxysm, if the room be sufficiently light, can see whatever comes di- 
rectly in front of himj he can hear the breathing of his bed-fellow, 
and is conscious of conversation when it takes place in his presence; 
he has the sense of touch, for he is aware of his contact with the bed- 
clothes, and also of irregularities in their position under him; he can 
move his under jaw with ease perpendicularly, but has no power to 
produce a lateral motion^ he knows that he breathes but with much 
difficulty; he has the power of natural voice, but not of speech, and 
volition is perfect, but her organs are not obedient to her mandates. 

These are the facts from which we are to determine its pathological 
character, and upon which we are to build our hope of success in re- 
moving the obscurity hitherto surrounding the location and cause of 
this disease. 

The remote causes of this affection are violent mental agitation — 
fear — also great fatigue of body, and in truth whatever wearies the 
mind or body beyond their healthy endurance. But the most pro- 
lific cause is overloading the stomach before retiring to rest. The 
proximate cause consists in one part of the system requiring a greater 
amount of nervous power than is naturally appropriated to it, and as 
the extremities of the nerves cannot produce the deficiency, this ex- 
tra quantity of nervous influence must be supplied from some other 
part, consequently the part from which the deficiency is obtained is 
left in an unnatural condition, and thus results this affection. 

I will here state that I consider this disease to be purely nervous, 
and that the attendant dyspnoea and congestion are effects consequent 



Fosgate on Nightmare. 83 

upon it, and not the cause as has been believed and supported by pa- 
thologists. But before I proceed further, I would remark that the 
nervous texture is subject to the strongest anomalies connected with 
the human system, and that its various uses are continually merging 
into light, and that previous to the late discoveries of distinct func- 
tions connected with different filaments, and the regularity of i\\Q, 
origin of each set of nerves, and that their qualities depend upon the 
part from which they are derived, the subject was enveloped in com- 
parative obscurity. It is by carefully regarding these late discoveries 
in connexion with the phenomena presented by the disease, that its 
pathology can be determined. 

The anterior column of the spinal marrow and the nerves arising 
therefrom, are the seat of incubus. This being the case, the nerves 
of feeling arising from the posterior column of respiration, arising 
from the lateral column of vision and hearing, originating from the 
brain and the brain itself, are not involved in the disease. We are 
now able to account for its various phenomena. 

The faculty of the mind in reasoning, the active state of the memory 
and volition are qualifications belonging exclusively to the brain, and 
are not the subjects of this disease. 

The sense of feeling is the peculiar property of the filaments origi- 
nating in the posterior column of the spinal marrow, and therefore is 
not operated upon by this affection. 

The act of respiration is continued, but somewhat impaired, being 
very laborious. The muscles performing this operation are supplied 
with three sets of nerves all differing in their functions^ one set from 
the anterior column being the nerves of voluntary motion, and com- 
bined with another set from the posterior column conveying sensation, 
and a third set from the lateral column being those of respiration. 
The first set which is the seat of the disease may be regarded as the 
cause of the dyspnoea. The process of breathing is effected by the 
nerves of respiration in conjunction with those of volition, the first 
not being sufficient to the perfect performance of this office without 
the cooperation of the last. If from any cause the voluntary muscular 
action is suspended, the motion of the thorax is diminished, and an 
intolerable sense of pressure and suffocation is the result. From this 
circumstance the name of the disease originated, (incubus, from the 
Latin, signifying one who lies upon.) The tremulous motion experi- 
enced in the abdominal muscles after the paroxysm I conceive to be 
caused by an irregular return of nervous influence to them. 

All the muscles of the face are subject to the will, but are unaf- 
fected by the disease, and the countenance expresses great anxiety. 



84 Fosgate on Nightmare. 

These muscles with many of the neck are supplied by the portio 
dura, which is a nerve of respiration, expression, and volition in the 
muscles to which it is distributed. This accounts for our being able 
to move the lower jaw in a perpendicular, but not in a lateral direc- 
tion. The muscles of the face and throat being competent to produce 
this motion without the assistance of those of mastication, these lat- 
ter being supplied with a branch from the fifth pair, and of these 
muscles the pterygoideus externus is that which causes the lateral 
movement. Over these muscles of the jaw we have no controul. 

To account for the faculty we possess of seeing objects that are in 
a line perpendicular to the face during the paroxysm, and only those 
in that direction, require our attention to the functions of the various 
parts of which the organ of vision is composed. And here I shall 
again take advantage of the discoveries of Mr. Charles Bell, in 
the physiology of the nervous texture. 

It will be readily seen that as the optic nerve arises from the brain, 
its function cannot be impaired; but when we consider that the situa- 
tion of the globus oculi during sleep excludes the light, both from 
the elevated position of the pupil and the closure of the palpebra, 
and in addition to these the inactive condition of the voluntary mus- 
cles, during the paroxysm of incubus, we are perplexed to solve the 
problem. 

The muscles of the eyelids are supplied with nervous twigs from 
the portio dura, and hence, are not under the influence of the dis- 
ease. But how shall we account for the phenomena of vision, when 
it is known that the pupil is raised above the margin of the elevated 
lid.^ The ball rises from the relaxation of the superior oblique, and 
this muscle is furnished with a distinct nerve, which arises from the 
summit of the column that originates the nerves of respiration, con- 
sequently the disease does not aff'ect this muscle. Now, all the mo- 
tions of the superior palpebra are accompanied with an opposite 
movement of the superior oblique, as when the lid falls the eyeball 
rolls upwards, and vice versa. These actions are attendant upon 
each other, and are both voluntary and involuntary. The nerves of 
respiration endow their muscles with this double quality. But these 
movements only open the eye and bring the pupil in the most ante- 
rior direction, and further command over this organ they have none. 
The recti muscles give the various directions to the eye, they receive 
their nerves from the motor division, and are purely for voluntary 
motion. 

The sense of hearing is conveyed to the sensorium by the portio 
mollis, a nerve originating from the brain. But the function of this 



Fosgate on Nightmare. 85 

apparatus would avail nothing without the action of the muscles con- 
nected with the internal structure of the ear. These muscles are fur- 
nished with branches from the fifth and seventh pair of nerves, and 
as the seventh pair are nerves of voluntary muscular motion to the 
face and neck, we may safely conclude, that the same influence is 
exerted on these muscles, producing the necessary action for convey- 
ing sounds. 

The larynx receives its nerves in four branches from the par va- 
gum, which is the principal nerve of respiration, and by these we are 
endowed with natural voice, which we are capable of exercising when 
under the influence of this disease; but of the faculty of speech we 
are deprived, the tongue being furnished with its nerves of voluntary 
motion from the anterior column of the spinal marrow being the 
twelfth pair of Mr. Charles Bell. 

The action of the heart continues. This centre of the circulation 
so necessary to the continuance of life in every condition, is supplied 
with branches from the par vagum, and when its functions are de- 
ranged in this disease, it is from sympathy with the lungs. The mo- 
tions of the heart are less under the influence of the brain than the 
lungs are, and it becomes disturbed, not from its dependance upon 
the brain, but from its association with respiration; and I have before 
stated, the derangement of respiration is caused by a suppression of 
nervous influence to the voluntary muscles of the thorax and ab- 
domen. 

Rest in general, renders the healthy pulse slower, but when the 
stomach is oppressed with a heavy meal, and the person falls asleep, 
the pulse becomes much quickened. As the powers of volition sub- 
side, that of sensorial action increases, and the action of the heart 
and arteries are augmented by their consent with the aggravated ope- 
ration of the stomach. This being the case, incubus cannot be the ef- 
fect of stagnation of the blood, for it invariably occurs under some 
extra irritation. 

The theory of this disease based on congestion is entirely hypothe- 
tical. The symptoms indicating this state of the vascular system are 
neither sufticiently numerous nor well marked, to have any weight in 
fixing it as the proximate cause. What congestion there may be is 
more easily accounted for as an effect, than as a cause of this disease. 

Incubus differs from coma, inasmuch as in the latter there is neither 
consciousness nor volition; and in asphyxia consciousness is lost, vo- 
lition is suspended, and there are no perceptible respiratory or arte- 
rial actions. There is no suspension of volition during the paroxysm 

No. XXIX.— November, 1834. 8 



86 Fosgate on Nightmare. 

of nightmare, for the endeavours of the victim to be liberated from 
his suH'erings are very active. It differs from revery in being inter- 
cepted by the action of the voluntary muscles, produced either by the 
will, or by the application of external force. After a paroxysm of 
nightmare, we remember distinctly our ideas and sensations, but on 
recovery from a fit of revery, we have no recollection of what passed 
during: its continuance. It is a blank in our conscious existence. 

It is my firm opinion that death never is an effect of this disease, 
because, when the painful sensation acquires a certain degree of se- 
verity, the voluntary power will come into action and the disease 
ends. And we know from experiment that motion intercepts its pro- 
gress, and that the voluntary muscles universally come into action 
previous to dissolution, unless it supervenes upon typhus fever where 
the irritability of the system is worn out, or upon the effect of elec- 
tricity, or the exhibition of some of the virulent poisons, as hydro- 
cyanic acid, and as before stated, this action of the voluntary mus- 
cles ends the complaint, or in other words, the disease destroys 
itself. 

The course of treatment to be pursued in this affection, is prophy- 
lactic. The principal indication is to keep the nervous influence as 
equally balanced as possible. This is to be accomplished by prevent- 
ing extra excitement in the thoracic or abdominal viscera. Food 
should not be taken in large quantities immediately before retiring to 
rest, because when the stomach is engorged it requires under all cir- 
cumstances a greater amount of nervous influence than is appropri- 
ated to its natural action of digestion, but more particularly in the 
state of sleep, for then digestion proceeds more rapidly, and the ac- 
tion of the voluntary organs having ceased, the whole current of ner- 
vous power expended on them in their state of action, is drawn to the 
stomach with so much avidity that they are left without a sufficient 
amount to be acted upon by the will. 

To those habitually afilicted with this malady, I would recommend 
an alarm watch, set to awake them at short intervals, and kept at 
such a distance from their bed, as to oblige them to leave it when- 
ever it require resetting. The voluntary action thus produced will 
be sufficient to equalize the nervous influence. For in the proportion 
that the action of the voluntary powers return, that of the digestive 
organs decrease. 

In conclusion, the disease is purely nervous: secondly, it is conse- 
quent upon a deficiency of nervous influence in one part of the sys- 
tem, occasioned by a greater demand for it in another part^ and last- 



Gerhard on Pneumonia of Children. 87 

Ij, is confined to that division of the nervous texture designed en- 
tirely for voluntary motion, leaving all other functions of the organi- 
zation in their normal condition. 

Auburn^ Cayuga County^ N. Y, April 16th, 1834. 

[The following extract of a letter from the author of the preceding 
article to the editor, deserves to be quoted, as it shows the author to 
be himself a sufferer from the affection he describes: — " My views of 
the disease have been drawn from attentive observation of its pheno- 
mena, having advanced only such symptoms as have been experi- 
enced by myself. My opportunities for so doing have been more abun- 
dant than I could have desired. I have been more or less the subject 
of this affection since my earliest remembrance, and it has at all 
times engaged my most earnest attention."— Ed.] 



Art. V. Pneumonia of Children, By W. W. Gerhard, M. D. 

[Part 2d.] 

1 HE analysis of the forty cases of pneumonia occurring in children 
between the ages of six and fifteen years, shows that this affection in 
children of the ages just mentioned is characterized by bronchial res- 
piration, crepitus rhonchus, flat sound on percussion, fever, cough, 
&c. ; in short, the symptoms are precisely similar to those of the pneu- 
monia of adults. The disease has an origin marked by rather abrupt 
appearance of the symptoms, it has a definite duration, and in the 
large majority of cases terminates by the recovery of health. I have 
now to pursue the same method of analysis, and examine the observa- 
tions of children between the age of two and six years. The earliest 
period at which they are received at the Children's Hospital of Paris is 
two years, and I have therefore but a small number of observations 
relative to infants. 

I excluded from the first series all cases in which the affection of 
the lungs was evidently consecutive to another disease, such as mea- 
sles, small-pox, or tubercles if sufficiently advanced to furnish cer- 
tain indications of their presence. This second series was much less 
easily distinguished from the cases in which pneumonia is a secondary 
lesion, and does not present the same broad line of separation as the 
inflammation of the lungs in older children. The want of characters 
by which to designate at the first glance the cases of supposed idiopa- 



88 Gerhard on Fneumonia of Children. 

thic pneumonia in young children, is in strong contrast with the faci- 
lity of diagnosis in the inflammations of the lungs at an age a little 
more advanced. 

I have selected from the observations I collected at the Children's 
Hospital, sixteen cases of pneumonia occurring between the ages of 
two and six years, in which the disease was the least clearly depen- 
dent upon an antecedent affection. Of these sixteen cases, twelve 
terminated fatally, and four recovered; a result very different from 
that obtained in older children in whom but one-fortieth of the cases 
terminated fatally, instead of the immense mortality of three-fourths 
which was observed in the second series. Of course I do not mean 
that such would be the general ratio, or that such is the average re- 
sult even amongst the poor of Paris, but that, of the children sufficient- 
ly ill to be admitted into the Children's Hospital, three-fourths of those 
who seemed attacked with pneumonia, and whose age was less than 
six years died. The mortality of this series is not peculiar to the 
disease in question, a large majority of young children affected with 
different diseases die at the Children's Hospital. The following cases 
are examples. 

Case. Eugenie, set. three years, entered June 17th, 1833, into the 
girl's wards. Her parents, (intelligent,) gave the following details. 
Born in the country, but brought to her parents at Paris eight months 
ago, since that time she is weak, cannot walk, irritable temperament. 
A fortnight before her entrance she began to cough; heat of skin 
some days afterwards; no vomiting; diarrhoea of three or four dis- 
charges daily; appetite until last two days; thirst great, asking for 
drink, but frequently refusing it afterwards when presented to her; 
complains of pain in the head. 

18/A. Present state.— Hair fair; skin clear; eyes gray; moderate 
embonpoint; lips thin, rosy; nostrils in motion; decubitus dorsal; tran- 
quil; respiration high, forty per minute; cough rare; tongue reddish, 
moist at edges; abdomen yielding, tender at the umbilicus only. 
" Four leeches to the chest; demulcents." 

19^^. Skin hot; diarrhoea abundant during the night; thirst intense; 
face injected; some dilatation of the nostrils; stupor; acute cries when 
disturbed; respiration high, fifty to sixty; tongue and abdomen as 
before. 

9Xith» Stupor; ill humour if disturbed; some heat of skin and thirst, 
but she refuses with disgust the cup when offered to her; pulse 145; 
respiration fifty, irregular; auscultation practicable for first time; per- 
cussion nearly flat in whole posterior part of the right side, and in 
the axilla sonorous anteriorly, and in the whole of the left side; res- 



Gerhard on Pneumonia of Children. 89 

piration on right side anteriorly little expansivej inspiration and ex- 
piration nearly equally distinct^ same characters posteriorly; no rhon- 
chus; respiration on left side expansive, anteriorly and posteriorly 
without rhonchus or expiration. Syrup of gum; cataplasm to chest; 
milk. 

On the 21st the inspiration in the posterior part of the thorax was 
blowing on the two sides without distinct expiration; anteriorly ex- 
pansive on the left side; a little blowing on the right; percussion sono- 
rous on both sides anteriorly; obscure posteriorly on the right side; 
moderately sonorous on the left. 

On the 22d great sonoriety on percussion anteriorly on both sides; 
very obscure sound posteriorly, extending to the axilla on the right 
side; strong bronchial or tubal respiration in the upper two-thirds of 
the posterior part of both lungs; more marked in the right than the 
left; both inspiration and expiration tubal, the latter sometimes want- 
ing, but when heard even more blowing than the inspiration; inferior- 
ly, blowing inspiration with mucous rhonchus; no expiration; anterior- 
ly, respiration vesicular on both sides, but feeble on the right and 
mixed with sonorous rhonchus; bronchophony, (tubal,) in the upper 
posterior part of both lungs. 

Auscultation repeated on the 23d and 24th w^ith no change except 
greater feebleness of the respiration posteriorly. 

26^A. Bronchial respiration again louder, very tubal on both sides 
posteriorly; the face was flushed at first, afterwards pale; lips red, and 
nostrils always in strong dilatation. On the 24 th on each cheek there was 
an eruption of very small, pale-red, irregular spots; the eruption was 
still very pale on the 25th, a little more distinct on the 26th, on the face, 
but without a more determinate character, and not visible on the rest 
of the body. 

The ej'es were natural until the 24th, when they were injected and 
secreting a puriform liquid, which continued; features altered on the 
25th; skin hot, dry generally, but in full perspiration on the 23d and 
24th. Cough during the whole disease, at first dry, afterwards loose 
and mucous; respiration always high, frequently irregular, from forty 
to eighty inspirations per minute; voice and deglutition natural; de- 
cubitus always dorsal; pulse except the last day small, quick, from 
ISO to 140 per minute, sometimes irregular; tongue reddish at edges, 
grayish at centre, but never dry or brownish; anorexia complete; no 
vomiting observed; thirst always intense; diarrhoea during the whole 
disease abundant; on the 24th discharge of two or three lumbrici in 
the stools; abdomen yielding, and not distended at first, then retract- 

8* 



90 Gerhard on Pneumonia of Children, 

ed and finally a little distended with gas; never evidently tender 
on pressure. — Treatment. Syrup of gum; emollient cataplasms to 
chest and abdomen; potion of ether and Corsican moss after the 
discharge of the worms; the white decoction, (gelatinous decoction,) 
in the last days of the disease. 

9,7th» Face very pale; lips dark red; nostrils strongly dilated; in- 
telligence appears perfect; features haggard; agitation, throwing her 
arms from beneath the bed-clothes; decubitus more listless; respira- 
tion 70 to 75 per minute; pulse impossible to count, between 150 and 
200, very feeble but regular; cough feeble, provoked by the effort of 
drinking, which makes her reject abruptly the drinks offered to her; 
heat moderate, moist; tongue thick, reddish; thirst intense; diarrhoea 
abundant; percussion flat on the anterior part of the right side, sono- 
rous on the left; respiration tubal on the right, expansive and loud 
on the left; no auscultation practicable posteriorly. Death took place 
the same evening. 

Autopsy the 9>^th, forty hours after death. — Abdomen greenish, dis- 
tended with gas; slight oedema of the lower extremities. 

Head. Abundant liquid blood on the exterior of the dura mater; 
small fibrinous coagulum in the longitudinal sinus; some serosity in 
the cavity of the arachnoid, but little beneath it. Large sinuses of 
the pia mater generally distended, especially in the posterior part. 
Cortical substance rather violet; medullary a little more injected than 
usual. Ventricles contain a tea-spoonful of serosity; central parts 
white and firm; consistence of whole brain perfect; cerebellum, me- 
dulla oblongata, and pons varolii firm, similar in colour to the cere- 
brum. 

Thorax,'— Pleurss not adherent; each containing from one to two 
ounces of reddish serosity. — Right lung externally of a uniform vio- 
let-brown colour, except just along the anterior border of the upper 
lobe, where the colour is less intense. A few vesicles in this border 
still contained air, but the lung in all the rest of its extent was hard; 
not floating in water; resisting the pressure of the finger; containing 
no air except a few bubbles, which maybe forced from a few grayish 
points; smooth incision, marked with the whitish vessels and bron- 
chia; not granulated; of a liver-brown colour. Bronchia not thicken- 
ed nor dilated; containing some yellowish mucosity. — Left lung. 
Upper lobe offers anteriorly rounded elevations, owing to the dilata- 
tion of the vesicles in some of the lobules; posteriorly the pulmonary 
tissue is hard and reddish-brown in a mass the size of a hazelnut; in- 
ferior lobe in its whole extent impermeable to the air, dark red; in 



Gerhard on Pneumonia of Children* 91 

all respects similar to the inferior lobe of the right lung. Bronchia of 
the lower lobe as in the right lung; in the upper thej are nearly with- 
out mucus and more polished. Bronchial glands violet, large, not tu- 
berculous. Pericardium containing a little reddish serosity. Heart of 
ordinary size; fibrinous coagulum in each side, firm; red colour of its 
internal surface as well as of that of the aorta. 

Abdomen. Stomach slightly contracted, containing a whitish, vis- 
cous mucus; anterior face pale, yellowish-gray, rosy in the great tu- 
berosity, smooth, not mammillated, offering numerous little depres- 
sions regularly rounded, the largest half a line in diameter, without 
redness or elevation of the edges; mucous membrane not entirely de- 
stroyed. Posterior face of a tolerably bright red in its cardiac half, 
from very numerous vascular arborizations; the pyloric half is of the 
same colour as the anterior face. Slight mammillation along the mid- 
dle of the small curvature. Thickness of the mucous coat natural | 
consistence perfect; strips four or five lines in the great tuberosity, 
six to nine on the faces, and twelve or fourteen in the small curva- 
ture. — Small intestine. Containing a greenish-yellow mucus, and five 
or six lumbrici; mucous membrane tinged by the contents in the 
upper third; strips five to seven lines, easily detached. In the mid- 
dle third the colour is the same, with some fine vascular arboriza- 
tions in patches, one to three inches long; strips seven to nine lines 
long. In the last third mucous membrane pale, of good consistence. 
Glands of Peyer pale, reticulated, slightly elevated, except the last 
five or six, which are of an obscure red colour; rather more elevated 
than usual; the orifices of their follicles not visible, but not ulcerated; 
the subjacent tissue pale, not thickened. Isolated follicles visible 
only in the last foot of the intestine; nearly all with a central point 
and flattened. — Mesenteric glajids. Size of a grain of maize, violet- 
coloured, moderately firm; those near the extremity of the intestine 
rather larger. — Large intestitie. Contracted, containing some yellow- 
ish mucus; ccecum and ascending colon pale, except some sub-mu- 
cous vessels; follicles numerous, with the usual central point; strips 
five to seven lines. Mucous membrane of the transverse colon, as 
well as in the sigmoid flexure in general, pale, but marbled with 
some longitudinal patches of bright, dotted redness; strips four to 
five lines. Inferiorly, membrane pale, but of good consistence; strips 
seven to ten lines. Slight thickening of the mucous membrane in the 
superior half of the colon. — Liver of a brownish-lead colour, both ex- 
ternally and internally; two substances not distinct; incision smooth, 
yielding little blood; not fatty. Bile greenish, not abundant— /Sjo/een 



92 Gerhard on Pneumonia of Children, 

two inches long, one and a half broad, reddish-brown, firm. — Kid- 
neys rather pale, smooth externally, firm. — Bladder contracted. — 
Uterus violet-coloured, firm. 

I have preferred giving this observation in great detail, as an ex- 
ample of the most perfect kind of the lobular pneumonia. The whole 
of the right lung, except a few vesicles along the anterior border, was 
utterly unfit for respiration; hard, smooth, and reddish-brown: the 
same was true of the inferior lobe of the left, and of a portion of its 
upper lobe. The original character of this lesion, which at first ap- 
peared as hardened, detached lobules, which afterwards unite to- 
gether, was evident only in the superior lobe of the left lung; the 
other portions of the pulmonary parenchyma had become entirely im- 
permeable to the air. Although the induration of the pulmonary pa- 
renchyma was no longer confined to detached lobules, it still differed 
very much from the ordinary pneumonia of adults: instead of the gra- 
nulated, irregular surface, the indurated lung was very smooth and 
shining; its colour was rather bluish instead of the deep red which 
characterizes the pneumonia of the adult. The term hepatization is 
still applicable to the induration of the lungs of young children, but 
it is to the bluish, smooth liver of subjects in very early life, not of 
adults, that the lung must be compared. The hardness of the lung 
was remarkable; the lobulated induration is never so friable as the 
hepatized lung of an adult, but it is in general rather less resistant 
than in the present inrstance. The bronchia are not obliterated, but 
only compressed, so that the scissors could be easily forced through 
them; nor did they offer the redness and thickening almost always 
observed in the bronchia of an inflamed lung in an adult. The pleurae 
were not apparently altered. The other viscera presented very slight 
traces of disease. 

Passing from the anatomical appearances of the case to the symp- 
toms, w^e find that the cough began a fortnight before her entrance, 
the other symptoms commenced at various dates, w^hich were im- 
perfectly ascertained. On the 24th, there was a distinct though pale 
eruption of measles, which was possibly the latent cause of the pul- 
monary induration, at least the frequent coincidence of the pectoral 
aff*ection with the first appearance of measles, or even before their de- 
velopment renders this supposition extremely probable; the case is 
not a clearly marked idiopathic affection of the lungs. The child was 
also feeble, and the symptoms of the affection of the lungs were at 
first confounded with other phenomena. The local signs of the in- 
duration of the lungs were clear; respiration very high, from forty to 



i 



Gerhard on Pneumonia of Children. 93 

seventy inspirations per minute; obscurity on percussion, and after- 
wards flat sound on the affected side, corresponding to the de- 
gree of indurationj mucous rhonchus; then an obscure blowing inspi- 
ration, a little later strong expiration, and finally distinct tubal res- 
piration, or the most intense degree of bronchial respiration. The 
tubal respiration did not exist in the inferior third of the lung, al- 
though the induration extended to that part, but the inspiration was 
here blowing and marked by mucous rhonchus: the absence of the 
tubal expiration near the base of the lung probably depends on the 
anatomical difference in the distribution of the bronchia, which are 
smaller at the base of the lung, and almost always obliterated by the 
induration of the pulmonary tissue. The obscurity on percussion ex- 
isted before the bronchial respiration; this is usually the case in lo- 
bular pneumonia, and percussion generally indicates the existence 
of the disease at an earlier period than auscultation. There was of 
course no expectoration. The abdominal symptoms were thirst, ano- 
rexia, vomiting and diarrhoea; there was but little alteration of the 
alimentary canal to account for these disordered functions. 

Frequently the lobular pneumonia occurs in a child enfeebled by 
various affections, and at the time affected with a catarrh of some du- 
ration; a remarkable instance was furnished by the following case. 

Observation. — Duplay, set. 5; this boy was in the ward appropriat- 
ed to diseases of the skin, his disease was a chronic oezema on the 
face and on a large part of all the limbs. On the 9th of November, 
1832, the eruption presented the usual characters, (thin scales on a 
reddish or nearly a brown ground;) frequent but loose cough; no diar- 
rhoea. Barley water; baths of soap and water. 

12th. Cough continues; eruption has not changed in character- 
Julep with syrup of poppies; emollient lotions; Goulard's cerate to be 
applied. 

15th. On passing by the bed of the patient I was struck by the ex- 
treme dilatation of the nostrils and evident difficulty of the respira- 
tion, one hundred and eight inspirations per minute, irregular; pulse 
150, quick, very irregular; strong bronchial respiration at the pos- 
terior part of both lungs. Two cups to the base of the chest; gum 
potion; sinapisms to legs; blisters to feet and legs. 

From the 15th to the 17th the pulse increased in frequency to 
nearly two hundred per minute; respiration 94; coma extreme; op- 
pression; face very red, even purple last evening; nostrils in motion; 
mouth closed; cough rare. Continue potion. 

18th. Profound stupor; skin dry, rather warm; respiration very 



94 Gerhard on Pneumonia of Children. 

irregular, seventy to eighty per minute; pulse 160, rather irregular; 
abdomen retracted, grimaces if pressure be made upon it; cough stifled. 
Nitro-muriatic acid in poultices to feet; gum linctus. 

Death in the night of 18th to 19th. 

Autopsy. — Exterior. Little lividity; skin in several points offer- 
ing brownish crusts; in others thin scales. 

Thorax. Pleura not adherent. — Left lung. The whole inferior lobe 
and the posterior four-fifths of the upper lobe were hepatized, the cut 
surface was smooth, nearly homogeneous in appearance, not granulat- 
ed, hard, of dark red colour, with the whitish vessels visible in the 
mass; fragments of the lung sink in water; the anterior border of the 
upper lobe is grayish, and permeable to the air. — Right lung hepa- 
tized in the whole of the lower lobe, which is similar to the lower 
lobe of the left; upper and middle lobes hepatized in their posterior 
half, grayish, and containing air in the anterior portion in which are 
some dark red masses formed by the induration of isolated lobules, 
which contract strongly with the permeable gray portions of the lung; 
bronchia violet colour, containing some mucus; no tubercles in the 
lungs, but the bronchial glands contain some tuberculous matter. — 
Heart at least twice the size of the fist of the child; a little lemon- 
coloured serosity in the pericardium; right ventricle distended by 
blood; right auricle by an enormous fibrinous coagulum; some coagula, 
and a very large quantity of curdled blood in the left cavities; walls 
of the heart of little more than the usual thickness; that of the left 
ventricle is three lines at its middle part; aorta pale. 

Neck. Pharynx, trachea and larynx, pale. 

Abdomen. — Stomach contracted, containing a little mucus, offering 
numerous rugas, which are of a bright dotted redness, especially in 
the pyloric portion; slight mammillation in the pyloric fourth; general 
colour of the mucous membrane pale, orange-red; consistence perfect, 
but thickness a little greater than usual. — Small intestine containing a 
yellow and not abundant liquid near the valve; mucous membrane 
generally of a dark reddish colour from numerous arborizations in 
the upper two-thirds; the redness extends to the glands of Peyer, 
which are neither thickened nor ulcerated, and retain the normal re- 
ticular aspect; a few isolated follicles near the valve, when the mu- 
cous membrane becomes more pale; consistence perfect throughout 
the whole length. — Mesenteric glands grayish and normal. — Large 
intestine containing some greenish faecal matter, contracted: nume- 
rous arborizations through its whole extent; moderate softening and 
some thickening of the mucous membrane; strips at most six to eight 



Gerhard on Pneumonia of Children. 95 

lines long, but rather more in the rectum. — Liver containing much 
bloody gall-bladder not distended^ bile greenish. — Spleen and kidneys 
firm. 

Head. Moderate quantity of blood exterior to the dura mater; 
little serositjin the cavity of the arachnoid, or below this membrane; 
vessels of the pia mater gorged with blood; cortical substance dark 
gray colour; medullary much dotted with blood; one drachm of limpid 
serosity in the two lateral ventricles. 

The preceding observation furnishes an example of lobular indura- 
tion occurring suddenly in a child enfeebled by a chronic disease of 
the skin, and affected with bronchitis and diarrhoea before the deve- 
lopment of the induration of the lungs. The latter affection is very 
frequently preceded by diarrhoea, which often continues some weeks 
before the appearance of the bronchitis, and still longer before the 
induration of the lungs has attained a sufficient extent to be recog- 
nised by the usual indications. In such cases the secondary nature 
of the lesion in question becomes evident. 

These two examples are given in detail as specimens of the dis- 
ease; some of the most important characters of the affection are no- 
ticed in the following table, which contains a short analysis of all the 
cases.* The cases numbered from one to eight inclusive relate to 
boys, the others to girls. In the first column the age of the child, the 
month in which he was brought to the hospital, and the previous state 
of health are mentioned. The duration, when ascertained with toler- 
able probability, is given in the second column; the commencement 
of the disease is dated from the existence of the cough, which symp- 
tom was the most certain indication of an affection of the lungs which 
terminated in induration, and was apparently the first period cf this 
disease. The third column refers to the parts of the pulmonary or- 
gans which were impermeable to the air. The fourth indicates the 
presence or absence of an inflammation of the pleurae, as shown by 
the presence of false membranes or purulent serosity. The fifth co- 
lumn marks the cases in v^^hich tubercles were formed in the lungs or 
bronchial glands. 

* Tables of great extent, or which embrace numerous details, are obviously 
not adapted for publication; but a short tabular view of some of the symptoms 
of diseases little studied renders the facts far more intelligible. 



96 



Gerhard on Pneumonia of Children. 



1. Mt. 5. Novem* 
ber. Feeble health. 


Duration. 
Unknown. 


Extent of Induration. 

Both lungs, especially 
the left, in nearly whole ex- 
tent. 


Pleurisy. 
None. 


Tubercles. 
None. 


2. Mt. 2. Febru- 
ary. Feeble health. 


Five months. 


Posterior three-fourths of 
left and half of light. 


None. 


None. 


3. iEt. 2. March. 
Disease of skin, 
(chronic.) 




Posterior half of the right 
and three-fourths of the 
left. 


None. 


None. 


4. .Et. 2. Januaiy. 
Measles. 


Six to eight 
weeks. 


Posterior three-fourths of 
the inferior lobe of both 
lungs. 


Slight adhesions 
in left lung. 


A few in the 
lower lobe of the 
right lung. 


5. Mt. 2. January. 
Diarrhoea of a year's 
standing. 


Three to four 
months. 


Right lung; yellow hepa- 
tization, except a little of 
theposterior part of the up- 
per and lower lobes. Left, 
idem. 


Adhesions in 
both lungs poste- 
riorly. 


None. 


6. ^t. 2. January. 
Diarrhoea for two 
months. 


Three weeks. 


Posterior parts of upper 
and lower lobe of the right 
lung, and lower of left. 


None. 


In both lungs 
and bronchial 
glands. 


7. ^t. 2. Febru- 
ary. Rachitis. 




Whole of right lung and 
inferior lobe of left. 


None. 


None. 


8. MU 6. Decem- 
ber. Cough of long 
standing. 


Six to eight 

weeks. 


Right lung in posterior 
half; left posteriorly. 


On both sides. 


In each lusg 
and in glands. 


9. Mt. 3. June. 
Feeble health. 


Twenty-five 
days. 


Both lungs, especially 
the right. 


None. 


None. 


10. ^t. 2. March. 
Chronic disease of 
skin. 




Posteriorhalf of the right 
and three-fourths of the 
left. 


None. 


None. 


11. Mt. 5. May. 
Tuberculous. 


Seven weeks. 


Inferior lobe of left, and 
posterior part of upper and 
lower of nght. 


Both lungs. 


In both. 


12. Mt. 3. Janu- 
ary. Cough from 
birth. 




Nearly the whole of right 
lung, and the lower lobe of 
the left. 


Slight adhesions 
on light side. 


None. 



But one of the cases contained in the preceding table related to a 
child over the age of six years; seven of the twelve patients were be- 
tween two and three years of age. The mean age, (exclusive of frac- 
tions,) is three years, or if fractional parts be counted, it will be be- 
tween three and three and a half years. We see that there is an in- 
terval between the ages of three and seven years, in which the form 
of induration now described is comparatively rare, and that its most 
frequent occurrence is in the younger children: this statement is not 
applicable only to the children old enough to be admitted into the 
Children's Hospital, it is also true, and in a still more general way, 
at the Foundling Hospital, where very few autopsies are made with 
out finding the lungs in a greater or less degree impermeable to the 
air. 



Gerhard on Pneumonia of Children. 9T 

The previous state of health was examined in all the twelve cases, 
and without anj exception it was found to be feeble, Sonie of the 
children were affected with chronic cough, others with diarrhoea, which 
is very frequently the prelude to the pulmonary disease; two were admit- 
ted from other wards in the hospital, where they had been treated for 
chronic diseases of the skin of very long duration: not one of the cases 
occurred in a healthy child. On the other hand it was shown in the first 
part of this memoir that the older children who presented the ordinary- 
form of pneumonia were with few exceptions in perfect health at the time 
of its appearance, and no case was regarded as a legitimate example 
of pneumonia unless the previous health of the child was perfect, or 
so little affected that no connexion could be traced between the chro- 
nic and the acute disease. If the same rigorous limitation were ap- 
plied to the form of disease now under consideration, it is obvious 
that its existence as an idiopathic affection would be more than doubt- 
ful, for the cases which I have taken as examples were selected be- 
cause the evidence of anterior disease was in them the least apparent: 
on minute examination we find, however, that even of these cases none 
was an original disease developed in a healthy subject, hence none could 
be looked upon as a strictly idiopathic affection, analogous to the pneu- 
monia of older children. I possess many other observations of pulmo- 
nary induration which are still further removed from the character of an 
original disease, for in those instances no doubt existed as to the se- 
condary nature of the affection, and it was not in accordance with 
rigorous induction to class them among the observations which admit- 
ted of comparison with the cases of older children affected with the or- 
dinary form of pneumonia. The classification which I have adopted, 
excludes all cases in which the secondary nature of the symptoms 
was evident, and explains in part the rarity of the disease in children 
older than two years, but younger than those in whom cases of ordi- 
nary pneumonia occur; in very young children it is difficult for pa- 
rents to recognise the first signs of disease, which are sufiiciently ob- 
vious in older ones, to make the nature of the affection perfectly 
clear. 

The duration of the pneumonia of young children was discovered 
with much difficulty, but in all cases it greatly exceeded that of older 
children; the least duration ascertained was three weeks; in some 
cases it extended to several months, and became really a chronic 
disease. In adults, or in older children, pneumonia is never, or at 
least only in rare and doubtful cases, a chronic disease, but in the form 
of it peculiar to young children its existence seems prolonged much 
beyond the duration of the first mentioned variety, and it does not 

No. XXIX.— November, 1834. 9 



98 Gerhard on Pneumonia of Children. 

appear subject to any definite law. The beginning of the affection 
was sometimes, though very rarel v abrupt; in general the cough was 
at first loose, and there was little apparent difficulty of respira- 
tion; these symptoms gradually increased, until the oppression be- 
came intense, and the respiration impeded to a degree much beyond 
what is ever remarked in the pneumonia of adults. 

The lungs were in every case indurated in a large portion of their 
structure; in no instance was the lesion confined to a single one of 
these organs. This anatomical fact offers a very remarkable contrast 
with the pneumonia of adults, in whom the disease but rarely extends 
to more than one of the lungs. The affection of both lungs was not 
a mere accident occurring immediately before death, the physical 
signs proved that both organs became diseased nearly at the same 
time, and in nearly the same degree. The extent in which the lungs 
were impermeable to air was very great in every case; in some so 
small a portion of the pulmonary parenchyma remained permeable that 
the child must have died of the physical obstruction to the circulation 
of the blood; in such cases the difficulty of the respiration was ex- 
treme. In no case was the lung infiltrated with pus, or in the se- 
cond degree of hepatization (yellow^ softening;) in a single* case the 
hepatized portion was of a yellowish colour, but in all the induration 
was great, resisting more or less on pressure, and although more 
easily crushed than a portion of healthy lung, the tissue was always 
much less friable than it usually is in the pulmonary inflammation of 
adults. The colour as described in the detailed cases which I have 
given, was a bluish-red, much less intense than that of ordinary he- 
patization; and as mentioned in those cases, the cut surface was 
smooth, shining, not granulated, and yielded on pressure a whitish, 
slimy mucus, instead of blood or pus. The peculiar manner in which 
the induration takes place was evident in some of the twelve cases, 
but before death the lesion generally becomes so extensive that its 
original aspect is retained in but a small portion of the lung. In cases 
in which death takes place from some other lesion than that of the 
lungs, the original character of the disease is more evident. The indu- 
ration if studied in a large number of subjects presents three distinct 
stages. If a lung be examined in the first stages, the greater part of the 
parenchyma is very soft, rosy or gray, little infiltrated with serosity or 
blood, and permeable; in other circumscribed parts of the lung the 
tissue is of a dark brown or bluish colour, very hard, and a shining, 
glossy aspect, very different from that of the healthy tissue. These 

* This case was an exceptional one in several respects. 



m 



Gerhard on Pneumonia of Childy^en. 99 

indurations are exactly limited by the cellular tissue interposed be- 
tween the lobules, and are not usually surrounded by the pulmonary 
tissue infiltrated with blood, and of diminished consistence: in this 
stage of the disease the name lobular induration is applicable to the 
lesion. In the second stage of induration the isolated lobules are 
more generally indurated; the lung if incised offers at first sight a ho- 
mogeneous appearance, but an attentive inspection shows that it is 
marbled with small, irregular, grayish spots, from which bubbles of air 
can be forced by pressure; these grayish spots are portions of the pul- 
monary tissue, in which the vesicular structure is still distinct, but 
surrounded by indurated portions of lung. Some care is necessary 
to distinguish the presence of vesicles in the spots described; they 
may be mistaken for the orifices of divided bronchia, or sometimes 
for softened portions of the lung, but pressure on the parts will always 
force out some minute bubbles of air, and render their vesicular struc- 
ture distinct. The third stage of induration presents the shining ho- 
mogeneous appearance described in the two detailed cases; the vessels 
are still visible as little whitish lines, and the bronchia are compress- 
ed, but with a little care they may be readily traced. The state of 
the bronchia differs from that in which they are found in ordinary 
pneumonia; in the lesion now described, they contain some whitish 
mucus, very rarely yellowish, or puriform liquid; the mucous mem- 
brane retains its shining, transparent appearance, and is not often of 
a bright red; in no cases do I find it described as thickened. The in- 
flammatory state of the bronchia is less intense therefore than in or- 
dinary pneumonia, and is not accompanied by the secretion of the 
viscid, rusty-coloured liquid, which is almost characteristic of the 
disease in adults. 

Inflammation of the pleurse, indicated by the presence of false mem- 
branes, or a little puriform serosity, is almost always found in adult 
subjects dead of pneumonia; so frequently that the name pleuro-pneu- 
monia was given by some writers to the disease. In the pneumonia 
of young children pleurisy is rare; of the twelve cases mentioned in 
the table, there were adhesion in five only; and of these adhesions 
some were cellular, perfectly organized, and had evidently existed a 
considerable time before death. When pleurisy occurs, it is there- 
fore an exceptional case. 

Four of the twelve subjects had tubercles in the lungs or bronchial 
glands. In one of these cases no tubercles were found in the lungs, 
although there were evident tuberculous deposits in the bronchial 
glands; this was an exception to the general rule. 

I shall now examine the symptoms of lobular induration, comparing 



100 Gerhard on Pneumonia of Children, 

them with those of the pneumonia of adults, or what is shown to be 
identical, the pneumonia of the older children, beginning with the 
symptoms dependent upon the thoracic organs. 

Cough was a symptom in every case, but it varied in different chil- 
dren, and offered changes in its character, corresponding to the dif- 
ferent periods of the disease. At tirst the cough was short, rather 
dry, it afterwards became more loose, and rather more frequent; to- 
wards the close of the disease, when a large portion of the lungs had 
become impermeable to the air, the cough was extremely feeble, and 
gradually became extinct. The voice was not altered in its character, 
but the breath became shorter with the progress of the induration, 
and both voice and cry became very difficult, and were sometimes 
wanting in the last days of life. Of course there was no expectora- 
tion; but when the mucus secreted in the bronchia was forced out by 
vomiting, it was whitish, glutinous, but never presented the viscid or 
rusty-coloured sputa of pneumonia. 

The frequency of the inspirations was very great; with one excep- 
tion not less than thirty-five per minute, generally from fifty to se- 
venty, but sometimes much more frequent, and in one case amount- 
ing to more than a hundred per minute. In one case only, the res- 
piration was slow, never exceeding twenty; this patient was ema- 
ciated from diarrhoea of some months standing, was tuberculous, and 
the extent of the pulmonary induration was not great; all these cir- 
cumstances explain the apparent exception. 

The physical signs of lobular pneumonia are at first limited to those 
dependent on the secretion of mucus into the bronchia, such as the 
mucous and sub-crepitous rhonchus. The sub-crepitous rhonchus fre- 
quently continued throughout the whole disease, and is never re- 
placed by fine crepitus as in the pneumonia of adults; fine crepitant 
rhonchus is never heard in the pneumonia of young children; but in 
one or two cases at the Children's Hospital the rhonchus was rather 
finer tl^an usual, and approached the ordinary crepitus. These cases 
were however exceptional, and the rhonchus usually regarded as cha- 
racteristic of pneumonia is scarcely found in young children. Bronchial 
respiration is not developed until the induration of the lung has extend- 
ed to a considerable portion of the parenchyma, and then it is chiefly 
confined to the upper and middle portions of the posterior part of the 
lung; in the lower lobe it is rarely heard from the comparative smallness 
of the bronchia, and their prompt obliteration by the progress of the 
compression. In a third of the cases the bronchial respiration was not 
distinct, even at the close of the disease. This absence of bronchial 
respiration is easily intelligible; to produce this phenomenonj besides 



Gerhard on Pneumonia of Children. 101 

the condensation of the lung, it is necessary that the bronchia should 
not be obstructed, and that the air should be forced through them 
with a certain degree of force in the inspiration and expiration. In 
adults, although from the accumulation of mucus, the bronchia are 
sometimes obstructed, a slight effort of coughing, or even a change of 
position removes the impediment to the passage of the air, and the 
bronchial respiration is reproduced; the impetus given to the air pas- 
sing through the bronchia is always sufficient to produce this sound. 
Young children cough more rarely, which allows the accumulation of 
more liquid in the bronchia; they also breathe with much less force, 
peculiarities which must render the bronchial respiration less distinct. 
There is however a character of the respiration in this affection which 
is almost peculiar to it; the inspiratory murmur, instead of being full 
and expansive as it is in healthy children, is short, obscure, blowing, 
and almost without the vesicular murmur; this obscure blowing in- 
spiration maybe accompanied with the mucous or sub-crepitous rhon- 
chus, or it may be alone heard; the expiration is rarely distinct, unless 
the bronchial respiration is fully developed, when it is usually louder 
than the inspiration. This blowing respiration is described with great 
difficulty, but practice will render it perfectly distinct. Percussion 
is frequently of more utility than auscultation as a means of diagnosis 
in lobular pneumonia. The sound is dull on both sides of the chest, 
but in different degrees according to the extent of the induration; as 
both lungs almost invariably become indurated at the same time, the 
sound yielded on percussion must be compared with that afforded by 
a healthy chest in a child of the same age. A common source of 
error in the percussion of the chest in young children arises from the 
comparison made by the observer of one side of the thorax with the 
other, and as the difference of sound is frequently slight from the 
similar degree of induration, the erroneous inference is that the lungs 
are not diseased. When the induration extends to a considerable part 
of the lung, percussion yields a perfectly flat sound. It is always im- 
portant to begin the percussion on the posterior parts of the thorax, 
as the anterior portions of the lung are scarcely ever diseased, and the 
child frequently becomes restless before the investigation is terminat- 
ed. It is scarcely necessary to add that percussion should be very 
gentle and always mediate; for this purpose no pleximeter is so con^ 
venient as the back of the finger. 

Besides the physical characters of lobular pneumonia, there are 
other signs not immediately connected with the functions of the tho- 
racic viscera, but still caused by the difficult respiration; these are the 
signs offered by the countenance, which in children furnishes an im- 

9* 



102 Gerhard on Pneumonia of Children. 

portant means of diagnosis. The face is flushed, livid, or irregularly 
red, in rounded patches on each cheekj the lips swollen and livid 
red^ the nostrils in strong dilatation at each irfspiration. These symp- 
toms occur in almost every case if the induration takes place with to- 
lerable rapidity; when it is extremely chronic, the want of respira- 
tion seems to accommodate itself gradually to the diminished extent 
of permeable parenchyma, and the dyspnoea is much less intense. In 
this more chronic state, the face becomes pale and emaciated, and 
the efforts of respiration are much less strong, although the mechani- 
cal obstacle is not really diminished. 

Of the symptoms not immediately connected with the functions of 
the thoracic viscera, diarrhoea was the most constant. Of eleven cases 
in which the frequency of the dejections could be ascertained, there was 
diarrhoea in every case but one. The diarrhoea generally continued 
throughout the whole course of the disease; in one or two cases it 
was present at the beginning only; the stools were greenish and very 
liquid in the few cases in which they could be examined. Vomiting 
was rarely observed after the entrance of the children into the hos- 
pital, but frequently occurred at the beginning of the affection, espe- 
cially after severe fits of coughing; I have but few observations in 
which the presence or absence of this symptom is satisfactorily stated, 
of these cases about two-thirds were accompanied by vomiting. The 
frequency of diarrhoea coincided wdth alterations of the mucous mem- 
brane of the large intestine. The thirst was always great. Appetite 
at first not impaired, but nearly destroyed when the dyspnoea be- 
came extreme, and apparently absorbed the whole attention of the 
children.* 

The cerebral symptoms varied according to the degree of oppression 
and the rapidity with which the induration of the lung had taken place. 
When the disease proceeded quickly and assumed the characters of an 
acute affection, the dyspnoea was extreme, and the stupor seemed in di- 
rect relation with the oppression; sometimes it was so intense that the 
children were nearly insensible to surrounding impressions. When 
the pneumonia was accompanied by less dyspnoea, and the disease 
advanced slowly, the cerebral functions were scarcely impaired. 

Treatment. — The treatment pursued by the physicians of tlie Chil- 
dren's Hospital did not differ essentially from that followed in the 
pneumonia of older children. The antiphlogistic method was pur- 

* The preceding" pages might have been Increased by an analysis of the anato- 
mical lesions. It is not, however, at present practicable to give a complete 
treatise? the points of primary interest are alone noticed. 



Gerhard on Pneumonia of Children, 10^ 

sued, but in the cases I witnessed no blood was taken from the armj 
either scarified cups, or what is still better, leeches were applied to 
the thorax in numbers varying from two to eight. Even this number 
of leeches should be applied with some caution, as the loss of blood 
from their bites is sometimes very great. External revulsion by sina- 
pisms, poultices, or blisters was frequently used, and small doses of 
opium with demulcents were given as internal remedies. The suc- 
cess of these means was so small that their analysis would scarcely 
lead to any results; I shall therefore reserve until the conclusion any 
further remarks upon the treatment. 

Case. Paquet, a boy, aged two years, entered December 24th, 1832. 
Anterior health good; cough for the last eight days, and vomiting re- 
peated on several days; diarrhoea for the last four or five days. 

December 9.5th. — Present state. Hair light; eyes not injected; pu- 
pils natural; face generally flushed, without rounded red spots| 
lips rosy; nostrils dilated, in slight motion; emaciation advanced; ab- 
domen distended, apparently tender on pressure; abundant diarrhoeaj 
cough loose, rather frequent; respiration fifty, high, heard at a dis- 
tance; pulse quick, 116; heat rather elevated; percussion sonorousi 
mucous and sibilant rhonchus on the left, followed by sub-crepitus 
when he speaks; on the right, mucous and sonorous rhonchus. Gum 
water; gum julep with tinct. opii. gtt. x. 

On the 29th the respiration had increased in frequency to seventy 
per minute; cough very frequent; obscure percussion on both sides of 
the chest posteriorly, and on the upper posterior part of the right side 
bronchial respiration strongly marked both in the inspiration and expi- 
ration; inferiorly the same respiration with some mucous rhonchus; on 
tlie left side, respiration bronchial but feeble, with sub-crepitant rhon- 
chus when he coughs. The examination of the chest became more diffi- 
cult, from the increasing restlessness of the child. On the Sd of January 
mucous rhonchus on both sides; percussion still obscure on both, poste- 
riorly. On the 8th, the percussion was sonorous on the left side, 
still a little obscure on the right. On the 13th, percussion sonorous 
on both sides; auscultation impracticable. Respiration, on the 3d 
and 4th of January, from 50 to 60 per minute. On the 8th it had 
fallen to 36, which frequency remained until the recovery of the 
child. The cough continued during the whole disease, and had not 
entirely ceased when the patient left the hospital; loose at first, but 
afterwards becoming harder and less frequent. Heat always mode- 
rate; pulse from 100 to 130 per minute, slower before the termina- 
tion, but counted with difficulty, from the great restlessness of the 
child; appetite good throughout the whole disease; diarrhoea abundant 
at first, suspended after remaining two or three days at the hospital, 



104 Gerhard on Pneumonia of Children, 

and again recommencing on the return of convalescence; abdomen 
always distended with gas; tongue whitish, moist, rosy at the edges. 
The countenance offered the intense livid colour in rounded circum- 
scribed spots on each cheek, more marked on the left than the right; 
this appearance continued, with some variations, during the whole 
disease. 

The gum julep with laudanum was continued. On the 28th, a 
Burgundy pitch plaster was applied to the back; after the 28th the 
treatment was limited to the gum julep and demulcents. Milk was 
allowed for diet on the 31st, and a light broth on the 1st. 

This case is one of the small number of observations of lobular 
pneumonia which have terminated in recovery. The disease was 
easily recognised from the bronchial respiration, cough, oppression, 
and the peculiar appearance of the countenance. The symptoms 
were, however, much less severe than in the fatal cases. The diar- 
rhoea was less constant and less severe than in the other cases detail- 
ed. The anterior history was not collected by myself, it was given 
to the house-physician on duty, and of course received without the 
same strict inquiry which is necessary on the part of a physician col- 
lecting a series of observations. The health of the child was said to 
have been good, it certainly could not have been sufficiently altered 
to attract the attention of the parents, but slight deviations from the 
healthy standard could only have been ascertained by a very rigid 
inquiry. 

Recapitulation.— 'T\\Q disease termed pneumonia in adults, charac- 
terized by cough, viscous and rusty-coloured expectoration, crepitant 
rhonchus, bronchial respiration, and in most cases fever and dysp- 
noea, is observed in children above the age of six years, and is at- 
tended in them by the same group of symptoms as in adults, except 
the expectoration, which is often wanting. This disease is rarely 
fatal, is almost always limited to one lung, generally to the inferior 
lobe, and occurs more frequently in the right than the left lung. The 
morbid appearances found on dissection of the lung, in a single au- 
topsy, were similar in children and in adults; a deep red, granulated 
surface, from which a reddish, purulent liquid could be forced by mo- 
derate compression, indicating the passage between the second and 
third degrees of pulmonary inflammation, or between the red and 
yellow hepatization. 

Before the age of six years, pneumonia is rarely if ever found with 
the same characters as in adults or the older children. It scarcely 
ever occurs in children in good health, so that it was impossible for 
me to find a single instance amongst the younger children whose pa- 
rents I had interrogated with care. Instead of beginning abruptly 



Gerhard on Pneumonia of Children. 105 

with sudden pain and difficulty of respiration, its progress is gradual, 
scarcely exciting attention until a large portion of the pulmonary pa- 
renchyma has become impermeable to the air. There is always mu- 
cous and often sub-crepitant rhonchus heard in the chest, but never 
or scarcely ever fine crepitus. Bronchial respiration occurs in many 
cases at the upper and middle parts of the lung, but in some in- 
stances the alteration in the characters of the respiration is limited 
to a short blowing inspiration without distinct vesicular expansion, 
and sometimes, but not always, followed by a short loud expiration. 
The anatomical characters of this variety of pulmonary disease are 
very different from those of the pneumonia of adults. The incised 
surface is smooth, shining, homogeneous, with no trace of granula- 
tions, and of a bluish-red or brown colour; upon this ground are seen 
whitish lines, which, if examined, will be found to be the pulmonary 
vessels. No purulent liquid exudes from this surface, nor does it 
offer the reddish-yellow aspect of the third degree of pneumonia. If 
the purulent infiltration ever occurs, it can only be in very rare in- 
stances. The consistence of the diseased tissue is much greater than 
is usual in the hepatization of adults, and is sometimes so great as 
to offer resistance to strong pressure The induration is at first con- 
fined to isolated lobules, which in their hardness and dark colour 
offer a strong contrast to the surrounding pulmonary tissue. The 
extent of the pulmonary induration is sometimes much greater than 
it-ever is in the pneumonia of adults, including nearly the whole pa- 
renchyma of the lungs. I have seen no instance in which the indu- 
ration was confined to a single lung; both were always affected. The 
part of the lung diseased was the posterior margin, including the 
lower lobe and the posterior part of the upper. This portion was not 
separated from the healthy parenchyma by a gradual transition from 
the diseased to the sound tissue, but was generally bounded by a line 
which would pass through both lobes parallel to the axis of the body 5 
the middle lobe of the right lung which does not extend to the pos- 
terior part of the lung, is rarely indurated. The duration of the in- 
duration was not fixed, extending sometimes to several months, and 
offering so great variations that no average time would faithfully re- 
present the duration of the disease. 

The name pneumonia is commonly applied to the two forms of dis- 
ease which we have investigated; these varieties are generally looked 
upon as so identical, that an eminent physician of the Children's 
Hospital has stated that few children die without pneumonia to a 
greater or less extent. There are however so many points of differ- 
ence betwen the two affections, that it is at present illogical to regard 



106 Heustis on Adhesion of the Placenta with the Uterus. 

them as identical. The first variety appears to be an ordinary inflam- 
mation of the lung, the second offers much greater analogy with the 
mechanical obstruction to the circulation of the blood through the 
lungs, which often occurs in old age; this opinion is corroborated by 
the fact of its occurrence, only as a secondary lesion in patients en- 
feebled by disease, and at the posterior parts of the lungs where the 
blood has a natural tendency to accumulate when the physiological 
powers are deficient. The lesion known by the name of pneumonia 
of young children is therefore not similar to the idiopathic inflamma- 
tion of the lungs, but is a mere secondary lesion occurring during the 
course of numerous aftections of childhood, especially bronchitis, 
measles, and chronic diarrhoea, and should be described as the lobu- 
lar induration of the lungs. 

The treatment which was pursued was similar to that employed in 
the pneumonia of older children; but the depletory measures seem 
peculiarly adapted for the very commencement of the affection, to 
diminish the quantity of blood passing through the lungs. Opiates 
were much employed, but the advantages derived from them are very 
problematical. After blood-letting the use of revulsives on the part 
aflTected, or still better over the whole cutaneous surface, offers the 
greatest probability of advantage. In chronic cases no revulsive is 
superior to the sulphur bath, made by dissolving one to four ounces 
of the sulphuret of potassa, according to the strength of the child in 
an ordinary bath; care should be taken not to prolong the bath if the 
child appears exhausted, and not to expose the face to the vapour 
from the sulphur. The treatment presents many questions for in- 
vestigation, the present inquiry was necessarily directed to those 
points of the natural history of the disease which could be studied 
with more accuracy than the treatment at the Children's Hospital. If 
the pathology of the aff*ection has been rendered less obscure, the ope- 
ration of therapeutic means can be traced with sufficient precision to 
estimate their value. 



Art. VI. On the Permanent Adhesion or Incorporation of the Plor 
centa with the Substance of the Uterus. By J. W. Heustis, M. D. 
of Alabama. 

X HE incorporation with, or permanent adhesion of the placenta, 
either in whole or in part, to the substance of the uterus, is a circum- 
stance of frequent occurrence in obstetrical practice, and one accom- 
panied with embarrassment, and not unfrequently with danger. 



Heustis on Adhesion of the Placenta with the Uterus. 107 

The placenta, in such instances, instead of forming a distinct vis- 
cus, slightly attached by intervening vessels, appears to constitute, 
as it were, a portion of the uterus itself, and of the same firm, hard, 
and resisting texture and consistence. In some women this pecu- 
liarity occurs at every pregnancy, in others it is accidental. The 
immediate and efficient cause in accidental cases, would appear to be 
a degree of preceding inflammation, or excessive irritation in the 
uterus, or placenta, or both, as producing a too copious effusion of 
lymph, and the consequent agglutination of the placenta to the con- 
tiguous portion of the uterus, in the same way as the pleura costalis 
becomes united to the pleura pulmonalis, by inflammation in either 
membrane. In consequence of this intimate union, the placenta is 
never detached in the usual time after delivery, but remains a source 
of irritation, pain, puerperal fever, and a tedious train of dangerous 
and distressing symptoms, until removed by the slow processes of de- 
cay and putrefaction, which are sometimes not finally completed 
sooner than a month or six weeks . 

In cases of this description it should be the business of the physi- 
cian to remove at the time of delivery, or as soon thereafter as may 
be, every portion of the placenta that is, or may be conveniently de- 
tached. And here I would take occasion to remark that the waiting 
for the contraction of the uterus some thirty or forty minutes, as usu- 
ally inculcated by obstetrical writers, is generally neither expedient 
nor necessary, at least I have never found it so in the course of my 
experience and practice. Were we to wait for the unassisted efforts 
of nature to bring about an expulsion, much time would be consumed 
to the no small inconvenience, pain and suffering of the patient; who, 
after the birth of the child, is anxious and impatient for the final de- 
livery of the secundines, that she may take the necessary refreshment 
of repose. Besides, the uterus and powers of the system have been 
already so much overstrained and exhausted by the birth of the child, 
that little remain for the expulsion of the placenta. I have, indeed, 
been called in to several cases of retained placenta, attended by prac- 
titioners of moderate experience, where I have found the patients en- 
during great distress from this very circumstance. I have, therefore, 
always afforded manual assistance, in a few minutes after the delivery 
of the child. For this purpose the funis should be kept tense with 
the left hand, extending it over the forefinger of the right, or vice 
versa, according to the position of the patient, in the direction of the 
axis of the pelvis: if moderate force is not sufficient to enable nature 
to bring about the expulsion, the hand should be introduced so as to 
grasp the placenta, which, except in cases of intimate adhesion 



108 Heustis on Mhesion of the Placenta with the Uterus, 

will generally follow the withdrawing of the hand with very little 
force. 

In all cases of flooding, the rule universally is to deliver the pla- 
centa with as little delay as possible. But this delivery we are not 
always able to accomplish, in consequence of the morbid adhesion ex- 
isting between it and the uterus^ here, then, we must detach and re- 
move without delay as much as we conveniently can, and trust to the 
partial contraction of the uterus, cold applications, anodynes and as- 
tringents for the balance. 

By way of illustration it may not, perhaps, be altogether uninte- 
resting to subjoin a case or two out of many that have fallen under 
my observation. And this I am the more inclined to do from the 
Bieagre accounts and descriptions of this disease to be met with in 
professional writers. 

Case I. On Sunday evening, October 2d, 1830, I was sent for in 
haste to visit Mrs. B. who had been taken in labour the preceding 
evening; she was a lady of great feebleness and delicacy of constitu- 
tion, and who had previously borne three children. Her confinement 
on such occasions had been uniformly tedious, and her convalescence 
lingering; being generally compelled to keep her bed for at least a 
month. I had been sent for over night, but being absent in attend- 
ance on patients at a distance, another physician had been called in, 
who had superintended the labour with the manual assistance of a 
negress midwife. She was delivered in little more than the ordinary 
time, about 4 o'clock A. M. of a fine, large boy, weighing nine pounds. 
After waiting nearly two hours, and no symptoms of contractions and 
expulsive etlbrts on the part of the womb to throw off the placenta 
taking place, the exhaustion and debility at the same time being 
great, together with the appearance of flooding, threatening to prove 
fatal by every minute's continuance, the attending physician, who was 
young, but well read and intelligent, expressed his apprehensions to 
the husband; the latter promptly requested him to do without hesita- 
ting or delay any and every thing which he might think necessary 
for the safety of the patient. He acccordingly introduced the hand, 
and attempted to deliver the placenta, but finding that it adhered 
very firmly, he desisted. I arrived in a short time afterwards. The 
physician related to me briefly the situation of the lady, and the 
course that had been pursued. I found her extremely weak, pale, 
and death-like, with a pulse, weak, thready, and scarcely perceptible; 
she complained that she was fast sinking, and must soon die without 
relief. The extreme symptom, however, of cold sweat, had not yet 
made its appearance, and was perhaps retarded by the coolness of the 



Heustis on Adhesion of the Placenta with the Uterus. 109 

weather. I perceived that there was no time for delay, since the loss 
of a hw more ounces of blood would in all probability have prostrat- 
ed the system beyond the power of recovery. Having oiled one hand 
I succeeded in insinuating it into the uterus, guided by the umbi- 
lical cord which I held in the other. I found the uterus high up, 
loose, pendulous and uncontracted. My disengaged hand I now ap- 
plied to the parietes of the abdomen, embraced the womb, and aided 
by pressure the other hand within the cavity of the uterus. The pla- 
centa was partially detached, but the remaining adhesions were so 
firm that they could with difficulty be separated; and a portion of the 
placenta was so firmly united that it seemed to form, as it were, a 
part of the uterus itself. Embracing, therefore, in my hand as much 
as was loose, and had been detached, I carefully withdrew it, and 
was gratified to find that the womb followed the placenta in its des- 
cent. A small portion of the after-birth I was under the necessity of 
leaving behind, to be removed by time. For the purpose of arresting 
the hsemorrhage, and producing uterine contractions, I used frictions 
with the hand previously immersed in cold water, applied a cold sad- 
iron to the region of the uterus, also linen cloths wet with cold water,^ 
and finally prevented the further external bleeding by the introduc- 
tion, ad plenum in t^Gg'iyzGsm, of fine linen cloths wet with cold water. 
The cloths were suiFered to remain in vaginam twenty-four hours, and 
then carefully removed; a slight discharge of blood ensued, though 
no more than natural, and what might be expected from the gradual 
solution of the clots in utero. 

On the fourth day from her delivery I was sent for in haste, and on 
my arrival was told that a very offensive discharge consisting of 
"lumps and clots" had taken place from the womb; an occurrence 
that I had anticipated, though not quite so soon. The patient was in 
great alarm; I, however, soon quieted her fears, by telling it was 
nothing more than what must necessarily happen in her situation, and 
that no danger was to be apprehended. In her weak and exhausted 
condition encouragement was necessary, though my own hopes and 
confidence were far from being sanguine. To correct the fetor and 
to act as a detergent, I directed the daily injection of a weak infusion 
of oak-bark with alum, and the subsequent use of tincture of myrrh 
sufficiently diluted. Injections of this kind proving too irritating, 
warm milk and water were substituted with the best effect; and to 
subdue the incipient peritoneal inflammation, warm fomentations were 
applied to the abdomen. From the first she had complained of an 
obstinate and unceasing head-ache, which she laid to the use of opium, 
given by the physician who had been in attendance at the time of her 

No. XXIX.— November, 1834. 10 



110 Heustis on %B.dhesion of the Placenta with the Uterus, 

delivery. This was considerably relieved by the application of two 
small blister plasters to the temples. 

On the ninth day I was again sent for in haste, about four o'clock 
in the morning. I found her with a very considerable fever, and 
great pain in the side, just above thehipsj the pain had been previous- 
ly wandering, but was now fixed and severe. Her great debility 
seemed to forbid the use of the lancet, and yet the urgency of the 
symptoms demanded decided and immediate relief. I therefore ven- 
tured upon a small bleeding, and took away a little more than half a 
tea-cupful of blood, a quantity in her situation proportionably equal 
to a quart in a robust individual. After the bleeding the pulse be- 
came softer and slower, and the pain soon subsided. In a short time 
after the bleeding a table-spoonful of castor oil was exhibited. I left 
her much relieved. Visiting her in the evening I found that the pain 
had entirely subsided, and that the fever had nearly disappeared. 

From this time she convalesced slowly, being occasionally much 
affected with head-ache, particularly in the evening; though for a day 
or two after the venesection she had been quite relieved from it. On 
account of this disposition to head-ache I was under the necessity of 
discontinuing the use of the bitter decoction and quinine. The bowels 
were much disposed to constipation, a condition that always aggra- 
vated her other symptoms. The stomach rejected all the ordinary 
cathartics; I therefore prescribed senna and manna. These also 
proved extremely disagreeable in their operation, producing in her 
weak state great debility and prostration. She was therefore advised 
to trust the regulation of her bowels to diet, and the daily use of 
enemata. 

About a month after her confinement she was seized with a dull, 
heavy pain and distressing sensation in the right hip and iliac region, 
rather exteriorly to the pelvis, and deep-seated; together with numb 
and dead sensation extending down the thigh and leg of the same side. 
These were relieved by the use of stimulating frictions and the warm 
pediluvium. 

Her convalescence was finally aided by the use of infusion of Co- 
lombo and the muriated tincture of iron. Tonics of a more stimulat- 
ing nature as quinine, decoction of bark and gentian, &c. at an early 
period were found inadmissible, on account of their exciting a fever- 
ish state, and greatly aggravating the pain in the head. 

Case II. On the 31st of March, 1832, I received a message request- 
ing me to visit Mrs. B s, who was represented as being in labour. 

As the patient was nearly thirty miles from my residence, it was late 
in the evening before I arrived. She informed me that she had been 
affected with labour pains for two days, which where sometimes severe, 



Heustis on Jidhesion of the Placenta with the Uterus. Ill 

and that she was in a constant state of suffering and distress. The 
pains, however, were irregular, erratic, less severe in the side, and 
more concentrated in the loins. These symptoms, according to her 
calculation, were six weeks anterior to the completion of her gesta- 
tioni and were probably brought on in consequence of the fatigue she 
had undergone a day or two previously, in riding a distance of eight 
or nine miles in a gig, from her own residence to that of her father's. 
For more than a month there had been frequent discharges of water 
from the uterus; previously to which discharge she would suffer much 
pain and oppression from the accumulation of fluid, and from the 
distention of the abdomen. These discharges, I have no doubt, pro- 
ceeded from a rupture of the foetal membranes, and consisted of the 
liquor amnii itself: this I infer from the fact that there was no effu- 
sion of water during the whole process of parturition. 

Soon after my arrival I proceeded to ascertain the situation and 
progress of the labour. I found the os uteri dilated, and the head of 
the child presenting about three or four inches from the os externum. 
Her pulse was frequent, indicating excitement, pain and irritationi 
as, however, the strength appeared to be but little impaired, and as 
there was no hsemorrhage, I did not consider that there was any 
urgent necessity for immediate delivery. She had been bled the day 
before, and I now directed an aperient, and as there w^as some sore- 
ness of the abdomen, directed warm fomentations. I then left her, 
with directions to apprise me of any aggravation of symptoms. In 
the morning I found her much the same; still suffering from irregular 
and inefficient pains. She was now anxious for delivery, yet appre- 
hensive of consequences. Upon advising with the attending physician 
it was determined to cut short her sufferings by using the secale cor- 
nutum. About eight or ten grains were accordingly given in a little 
water. In a few minutes the pains increased, and becoming more 
severe, concentrated and unyielding, the patient was delivered in less 
than an hour from the time that the ergot was exhibited. The child 
was small, livid, and almost exanimate; and as the cord still pulsated, 
the connexion with the mother through that medium was allowed to 
continue for about ten minutes, at the end of which time respiration 
"was established. The child now assumed a deep, universal, and fiery 
red, and in several places the cuticle was removed, exposing a raw 
surface. The foetus had doubtless suffered greatly from the discharge 
of the water during the latter period of gestation, deprived of its na- 
tural and proper element, and being firmly embraced and compress- 
ed by the investing parietes of the uterus, its development was retard- 
ed, the circulation impeded, and the skin irritated and inflamed. It 
lived but about twelve hours. 



112 Heustis on Adhesion of the Placenta ivith the Uterus, 

I had been informed of the dangerous consequences resulting from 
the previous labours of this lady, and the repetition of the same were 
again apprehended, viz. retention of the secundines. After waiting 
the usual time, fifteen or twenty minutes, I deemed it expedient to 
ascertain the state of the uterus and its contents. The womb was 
contracted, firm and globular above the pubes, but upon conveying 
my hand along the cord to the placenta, I found it adherent, firm, 
hard, unyielding and inseparable, apparently incorporated with the 
uterus itself. As there had been no separation of the placenta, so 
there was no flow of blood subsequent to delivery; she was now com- 
paratively comfortable; the nervous and vascular irritation had sub- 
sided, and the pulse soft, equable, and natural. Finding that nothing 
further could be done at present, I left her, with advice to the at- 
tending physician, of which the following is a summary. To guard 
against fever and inflammation, by attention to diet and the state of 
the bowels, elixir of vitriol two or three times a day; should tender- 
ness of the abdomen come on to use warm fomentations; when symp- 
toms of decay and decomposition should take place in the placenta, 
to use frequent injections of warm milk and water, and subsequent- 
ly a solution of the chloride of lime, observing strict quietude and 
rest, and avoiding everything of a heating and stimulating nature. 

Three days subsequently I again visited Mrs. B- s, I found her 

quite as v/ell as could have been expected. She had hitherto experi- 
enced but little fever or uneasiness. On the day of my arrival, how- 
ever, there had been some increase of uterine pains, and during my 
absence there had occurred at one time a considerable gush of blood. 
Of this, however, there was no repetition; and the presumption is that 
a partial separation of the placenta taking place, the haemorrhage was 
speedily arrested by the prompt contraction of the uterus closing the 
patulous and bleeding orifices. Decomposition had now taken place 
in the retained and extraneous mass, as indicated by the fetor. Upon 
examination, although the cord had been removed, I reached the pla- 
centa with little difficulty, the os uteri being patulous, and the other 
parts lax and yielding; the fimbriated circumference of the membranes 
hanging loose, so as to be readily seized with the fingers, but their 
texture was still firm, nor could the placenta be in the least detached 
by any moderate degree of force that prudence might authorize. 

After delivering the necessary directions, which were much the same 
as those I had previously given, I left the patient under the care of 
her attending physician, a relative of her's, and a young man of much 
cleverness and promise in his profession. 

I saw her no more, but learned that her recovery was slow, linger- 
ing, and painful, although she now enjoys tolerable health. 



Charlton on Cases of Retained Placenta. 113 

Art. VII. Remarhs on Cases of Retained Placenta. By T.I. CnARLTONy 
M. D. of Bryan County, Georgia. 

IN the southern states, parturition is generally an easy and safe pro- 
cess^ deformity of the pelvis is a rare occurrence, and rigidity of the soft 
parts so frequently retarding and rendering labour hazardous in the 
north, is here not often met with, or easily remediable. I do not think I 
am hazarding any thing in asserting, that at least one-half of the fa- 
tal terminations of the cases of parturient women are attributable to 
the placenta, either to its partial separation, and the consequent hse- 
morrhage, or to its retention in the uterus for a length of time be- 
yond the proper period for its expulsion, and to the state of extreme 
prostration and fever resembling typhus which follows. This last oc- 
currence, (the subject of this paper,) is infinitely rarer than the first 
or haemorrhage, and can only be accounted for by the most culpable 
negligence in permitting the retention to exist so long; or by the un- 
usual circumstance of a portion of the placenta being schirrous and 
firmly attached to the womb. Having met with cases of this kind, in 
which the retention had existed from three to six days before I saw 
them, and having had to treat them more from inference and ana- 
logy than from any specific method I could find in books, I have 
thought it might not be altogether useless to give the history of the 
cases and the mode of treatment adopted. 

Jeanette, a coloured woman, had miscarried four days before I 
saw her, the child was of the seventh month, and had died within an 
hour after birth; the midwife had attempted to bring down the pla- 
centa by pulling at the cord, which she ruptured; she had also made 
frequent attempts to detach it from the womb, but said she had found 
it impossible to accomplish this, the adhesion being so firm as to ren- 
der it probable that a persistance in the attempt would have inverted 
the uterus. There had been but little flooding, and the womb had 
contracted, (according to her statement,) around the after-birth, but 
not sufficiently so as to make this a cause of retention. 

On the fifth day I saw her; her pulse was 120; she had great heat, 
oppression, head-ache, coma, and in fine, all the symptoms which 
characterize typhus fever, so called; the fetor from copious discharges 
of a green water from the uterus was very great; the tenderness of 
the soft parts made an examination very painful; on making it, I 
found a portion of the placenta attached to the fundus uteri, which I 
brought away; it was highly offensive, and more than ordinarily com, 
pact in structure; the other contents of the womb were a semifluid 

10* 



114 Charlton's Cases of Retained Placenta, 

substance, which was no doubt the remaining placenta in a putres- 
cent condition 5 I brought away a part of this, but as the effort was 
attended with great agony from the inflamed state of the vagina and 
uterus, I did not think that a persistance in the attempt to bring away 
all the contents of the womb would be adviseable. I had in Dewees's 
Midwifery met with descriptions of such cases, in which he says 
that the prognosis is very unfavourable, but recommends as a pallia- 
tive for the local symptoms the use of injections of chamomile tea, 
with a little quicklime slacked in it. I was led, by seeing the power- 
ful antiseptic effects of the chloride of lime in other diseases, to infer 
that it might be useful in this instance. I accordingly directed an in- 
jection of a weak solution of it to be thrown into the vagina every 
hour, at the same time small doses of the acetate of ammonia were 
given every hour, and the free use of gum water and lemonade di- 
rected. I did not employ the bark, wine, or any other stimulant or 
tonic commonly recommended in similar cases, for the reason that I 
had never seen what was called typhus fever benefited by these re- 
medies, and the constitutional affection in this instance I deemed to 
be exactly the same with that which is usually called typhus, that is, 
a gastritis either primarily occurring, or superinduced. In this case 
the inflammation of the organs of generation, the pain, the mental ex- 
citement, were amply suflicient to have produced a sympathetic gas- 
tritis. I am borne out in this supposition by the following proposition 
of Broussais. " Intense irritation of all organs are constantly trans- 
mitted to the stomach from their very commencement. If the irrita- 
tion received by the stomach attains to the degree of inflammation, 
symptoms of gastritis appear, and as the brain is always then more 
irritated, it developes in a higher degree the sympathies which are 
proper to it and may even become inflamed." 

In this case there were all the symptoms that occur in primary gas- 
tritis — the dark tongue, the muscular debility, the depression, the 
coma, were all present. I treated it as a gastritis — I withheld all sti- 
mulants except the acetate of ammonia, which is the most transient 
one, and which I have found to be the only one I could safely use in 
cases of united inflammation and debility: I gave demulcent and aci- 
dulated drinks plentifully, and blistered the extremities. The chlo- 
ride injection, by correcting the foetor, rendered the patient's situa- 
tion much more comfortable; the fever also diminished considerably 
in twenty-four hours after the adoption of the constitutional remedies; 
the pulse became fuller and slower; the coma disappeared, and in 
fine, all the symptoms I attributed to the gastritis yielded to the re- 
medies administered for that disease. The soreness of the vagina, &c. 
was relieved by mucilaginous injections; the discharges from the ute- 

1^ 



Keckeley's New Splint for Fractured Clavicle, 115 

rus continued for about a week, at the end of which time all its con- 
tents had been discharged, and the lochia were not immoderate. 

In a similar case of a young married woman, where the local and 
general symptoms were even more aggravated by a retention of a 
week's duration, the same plan of treatment succeeded. 

At the time when these cases occurred, I had not read Broussais's 
Pathology, in which the above quoted proposition is contained, id est, 
that irritation of any other organ can produce gastritisi but I was fa- 
miliar with his other works, and was accustomed in the treatment of 
all diseases to watch for the symptoms of gastric irritation, and to 
present further indications, for although not as yet well knowing how 
these symptoms had been brought on, still I had observed that there 
were few diseases in which they did not appear first or last, and I 
had always found that the disease was diminished or aggravated in 
proportion to their intensity. 

Bryan County^ Georgia^ July 23fZ, 1834. 



Art. VIII. Description of a New Splint for Fractured Clavicle. By 
E. C. Keckeley, M. D. of Charleston, S. C. [Communicated in a 
letter to the Editor.] 

1 BEG leave to introduce to your notice a splint which I have used 
in the treatment of fractured clavicle. I have had but one opportu- 
nity of testing its utility, and that one satisfied me that it might be 
with advantage substituted for the more complicated bandage of De- 
SAULT. It appears to be adapted in an especial manner to the treat- 
ment of two kinds of cases. 

1st. Where the accident which causes the fracture produces so 
much injury to the parts over which the bandage, if applied, would 
pass, as to prevent its application. 

2d. Where, from the restlessness of the patient and his inattention 
to directions, the bandage is continually becoming loose, thereby 
frustrating the object intended to be accomplished by it. 

A case of this kind suggested the formation of the splint. A stoutj 
athletic man fell from a height and received an oblique fracture of 
his clavicle. The bandage v/as applied. The patient was so restless 
that as soon as he was left to himself it became loose. Knowing that if 
things were suifered to go on in this way no credit would be gained for 
the management of the case, a splint was made and applied. There was 



CL a^ 



116 Dickson on the Vis Medicatrix Naturm, 

no occasion for its readjustment during three weeks, at the expiration 
of which it was taken off, the cure being complete in every respect. 

The splint, of which the ac- 
companying figures give a re- 
presentation, is two feet three 
inches long and three and a 
half inches wide. 

Mode of Application, — Th e 
^ ^ end of the splint correspond- 

td d d hd ing to the uninjured side is 



f" t ] 



to be pressed close to the 
back of the shoulder and re- 

The upper figin-e exhibits a front view, and the lower a foiriprJ en hv rlr-iwino- +1ta hnn 
back view of the splint.-c, «, Are two bandages with 1-^"^^" bO Oy OraWing tne Dan- 
buckles attached to one end of each.— W, M, Are four rlarrp -fio-lif nnri rpfnininrv if \\\r 
morticed holes for the passage of the two bandages a, a.- "*^&*^ ''^S"'^' ^"*^ retaining It Dy 
<r, A portion of the splint padded, to prevent its bruising •mpanss nf flip KiifHo Pfoiri 
thepatient.-rf,rf, Two loops of leather tacked on the "*^^"^ 01 Ilie DUCKIC. rreVI- 
back of the splint, for the passage of the bandages, where quS to fixing: the bandaffC. it 
the morticed holes are too far apart for the breadth of the i , j , ° 

patient from shoulder to shoulder. Should be paSScd thrOUgh tWO 

loops on a small pad, which is to be placed in the axilla. This pad 
is used for the purpose of preventing the cutting of the bandage. 
After passing the other bandage through two loops, on a large cu- 
neiform pad, which is placed in the axilla of the injured side, it is 
drawn sufficiently tight and secured by the buckle. The last thing 
to be done is to place a handkerchief, doubled into a triangular form, 
in such a manner over the arm, the front and back parts of the tho- 
rax, as that it shall draw and confine the arm of the injured side close 
to the body, give it support, and prevent its falling down. By these 
means the three indications in the treatment are fulfilled. 

Charleston^ September Sd, 1834. 



Art. IX. On the Vis Medicatrix Naturse, By John Dickson, M. D. 

In reviewing the speculations and theories of our great predecessors, 
however fanciful and insufficient we may consider them in their ex- 
tent and application, we shall seldom fail to discover an important 
mixture of useful truth, and careful observation. Instead therefore 
of ridiculing them in the gross, or giving them up to contempt and 
oblivion, it is often well to study the facts they involve, and sift out 
the truth from the mass of error with which it was mingled in conse- 
quence of their scholastic prejudices and habits of theorizing. 



Dickson on the Vis Medicatrix Naturse. 117 

Few of the technical terms of the first founders of medical science 
are more frequently quoted to point a satiric paragraph in a lecture 
or essay than that which forms my present subject^ few of their high- 
wrought hypotheses are more familiar to students in this department 
of knowledge than the scheme which this term presents to view. I 
need not therefore quote at length. 

It will plainly appear, I think, on a candid examination of facts, 
that there was much truth, and very important truth, couched under 
this fanciful personification: and it is with a design to present some 
of these facts or general principles in a connected and impressive 
view to younger members of the profession that I have selected the 
subject. The results of these facts or principles will be seen to be 
practically the same as if such a personification were real and influ- 
ential in the system, and this may teach us neither to despise the 
works of the more ancient writers, nor to neglect to examine for 
ourselves the most ingenious disquisitions of the authors that now 
take the lead and stamp their image on all the doctrines current in 
the present day. 

1. ThQ first great principle I shall mention, which seems to give 
some countenance to the theory alluded to, is the reaction of certam 
vital powers against certain morbific agents. 

I am well aware that the term reaction is so often vaguely iised^ 
that all the ridicule directed against ancient theories maybe legitimate- 
ly levelled at some of those which have succeeded. Still as it is v/ith 
things^ not words, w^e have to do, I shall not despair of being imder- 
stood. By reaction I mean an excitement of some vital action, (such 
as Good calls instinctive,*) succeeding the effect of an application of 
external causes. This succeeding vital action often appears to be lit- 
tle if at all correspondent in its nature wdth the previous actions or 
states of the system. We cannot always trace the connexion philo- 
sophically, but experimentally, (if it be proper to make the distinc- 
tion,) we are compelled to notice the fact. It is always, however, a 
vital, and therefore a natural action which is thus produced, and 
when we have learned to expect its occurrence, we may be said to 
depend on a kind of vis medicatrix nature-— b, provision in the sys- 
tem for contingencies to which all the race must be exposed. 

The literal meaning of the term reaction, though not applicable to 
medical subjects, may serve to illustrate the truth which it figura- 
tively expresses. When an elastic body is compressed by a given 
force, so soon as that force is spent the elastic matter resumes its 

• This celebrated author attributes instinct to the mere material of vegetable 
as well as animal forms or parts whilst they are ahve. 



118 Dickson on the Vis Medicatrix Naturx, 

former extent and shape. So a morbific power being exhausted in 
producing a certain impression, there may be a nisus or tendency to 
return with a force proportioned in some manner to the previous im- 
pulse, into the original or some other native statej and as the re- 
bound of an elastic body will under certain circumstances carry it 
further back than the point whence it set out, (as v/hen the force of im- 
pulsion is greater than that of gravity,) so the reaction may often ex- 
ceed in violence and extent the diseased influence impressed in the 
first instance on the system. But I hope I shall not be thought guilty 
of attributing to these remarks any value beyond that which they 
have as similies or illustrations. They are not philosophical or scien- 
tific principles, but mere comparisons, and the use here made of them, 
may serve to show how we may justifiably and profitably employ the 
fictions of our predecessors^ they may often happily elucidate what they 
cannot prove, and assist us in that study which they ought not to super- 
cede. Elasticity here is notideniifted withy but only compared to vitality. 
I shall not enter at this time into an enumeration of all the re- 
actions capable of being produced in the system, or the agents con- 
cerned in their production. This would be a highly interesting and 
useful work, and it is here suggested to those who have learned more 
of pathology than I can profess to have done. 

2. Another principle to be here considered is the incompatibility 
existing between the diseased state produced by a given agent, and 
the present condition, either natural or diseased, of some other part 
or parts of the system. It is well-known that certain actions of the 
system or of its organs are so associated with others that the com- 
mencement of an action of one part or organ is at once attended or 
followed by a particular action of another part or organ. This ar- 
rangement often gives a check to the morbific agency of powers or 
principles eminently destructive to life — powers that are capable of 
suspending some of the vital actions. The strength and health of one 
part or organ thus becomes the strength and health of other portions 
of the system. 

The sympathy or association between organs or parts of the body, 
whence the incipient or increased action of one excites another whose 
action is curative of the excessive action of the first, is a matter of 
experience and common observation^ and this is but another way of 
stating the same principle. And it may be added that even when the 
sympathy brought into action does not directly involve a curative 
tendency, diseased excitement may be lessened in a particular organ 
by being diffused or extended to others, which are intimately asso- 
ciated with that organ. Under this general head we may place per- 
haps the eftect of derivatives, and the resolution of inflammation in 



Dickson on the Vis Medicatrix Naturse. 1 1 9 

SDme circumstances. Further from the natural combination of certain 
actions, such as are not interrupted or weakened bj the morbific 
cause, often start and support those which are interrupted or impaired. 
S. Certain diseases, it is admitted, have a natural course which they 
run through and then cease. It may, for aught we know, be true of 
all diseases, or of any disease whatever, in a constitution sufficiently 
strong to endure the continuance of the disease throughout its various 
stadia. Some of those diseases which are known to have such a re- 
gular and natural course kill the weakly, while the strong live through 
them. Now the supposed vis medicatrix may very well be imagined 
to be in operation in some cases of the latter kind, where the disease 
existing is not known or believed to have such a natural course endins: 
short of a fatal event. 

4. Habit, a power, (shall I term it?) still so little understood or es- 
timated, is in many cases the true vis medicatrix naturse. It con- 
tinues the vital actions in spite of the deteriorating effect of disease, 
and often seems to sustain life or the continuance of existence, where 
the vital actions are scarcely performed. Nothing else seems suffi- 
cient to explain the maintenance of life under the most unfavourable 
circumstances in certain cases; and this we are compelled by facts to 
receive as the sufficient reason. 

5. Life itself, the unknown principle which we may just consider 
as the antagonist of disease in every part — life itself is deserving of 
this long disputed title. All the powers of the body may be with strict 
propriety resolved into this, i. e. life, for whatever may be the quali- 
ties of the mere m.atter of which the frame is composed, no purposes 
of animal existence can be answered by the relation between that 
matter as such, and the external world. Life includes every organ 
with properties entirely distinct from any thing it possesses, consi- 
dered as a mere mass of a given chemical composition, or weight, or 
form. No sooner is it withdrawn than chemical actions take place, 
w^hich could not otherwise be effected. And what is of more import- 
ance in this place, it is only while life is continued that any curative 
means we institute can produce the appropriate effect. The chemical 
action of a substance introduced into the stomach is not, (at least ge- 
nerally,) the effect we aim at when we administer it as a remedy. 
The chemical action might take place after the extinction of vitality 
in the organ to which it is applied, but its effect as a remedy would 
then be looked for in vain. I have purposely omitted the considera- 
tion of surgical cases in which the thing is obvious to the eyes. 

From these reflections we may I think perceive the force and pro- 
priety of such language as that on which we have been animadverting. 
The principal evil no doubt arising from the employment of such terms 



120 Eve on the Treatment of Gun-shot Wounds, Sj-c. 

is that from their indeterminateness, the student is at a loss how to 
apply them, and may even at length almost forget that he is dealing 
in mere personification, while he brings in as real agents to cut the 
knot of everj difficulty he meets with, those qualities which have no 
existence by themselves but must inhere in something tangible and 
evident. 

To show the necessity of caution in this respect, and to assist the 
student in exercising it, are the objects in view in these brief para- 
graphs. 



Art. X. Observations on the Treatment of Gun-shot Wounds.) Ul- 
cers, Src. By Paul F. Eve, M. D. Professor of Surgery in the 
Medical College of Georgia. 

A PRINCIPAL object of this communication is to lay particular 
sti'ess upon the importance of dressing wounds and recent ulcers 
with the chlorides of lime and soda. The most intelligent surgeons 
now depend upon fine lint kept wet with cold water, leeches, some- 
times emollient poultices, perfect repose, depletion, &c. in the treat- 
ment of gun-shot wounds, which, together with the chlorides, will 
be found superior to any plan yet proposed. This treatment combines 
the advantages of the materials required being easily obtained in al- 
most every situation^ of a most efficacious disinfecting agent which is 
of much importance in camps and hospitals being employed; of being 
decidedly the most agreeable of all other methods of treatment to the 
feelings of the patient; and lastly, of greatly accelerating the healing 
process. 

The manner of using the chlorides is in solution in water. 
As a general application to wounds and recent ulcers, an ounce of 
dry chloride of lime to two pints of water, or two drachms of the 
chloride of soda, (of Labarraque,) to a pint of water, is found to be 
the best proportion. Confessedly, no agents of the Materia Medica 
possess greater disinfecting properties; but however satisfactory the 
chemical operation in this process may be understood, the same fa- 
cility or perspicuity of explanation is not apparent, by which they 
promote healthy granulation and cicatrization. While speculation 
is purposely avoided, it may be inquired, does not the very union 
of the; chlorine gas of the chloride with the hydrogen of the watery 
particles or gas secreted by the surface of a wound or ulcer, produce 
an alteration at once destructive of putrefaction and irritating mat- 
ter? and besides the result of which combinationj we have the alka- 



Eve on the Treatment of Gun-shot Wounds, <5'C. 121 

line base, soda or lime, the action of which is known to be salutary 
in such cases. 

Of the two preparations, the preference is given to the chloride of 
soda for recent solutions of continuity. A tea-spoonful of this arti- 
cle in a pint of water imparts to it an oleaginous appearance and sen- 
sation when touched, wliich any quantity of the chloride of lime never 
does, and this fact cannot therefore depend, as has been suggested, 
on the superior causticity of the one over the other. It is conceived 
that this very impression of the solution in water being milder, ren- 
ders the chloride of soda better adapted for recent wounds than the 
same preparation of lime. 

These agents I have found strikingly useful in gun-shot wounds 
accompanied with primary or secondary haemorrhage, or luxurient 
granulation. The medium through which they were applied, a pledget 
of lint, operated by compression in arresting the flow of blood, or 
suppressing the fungous growth, and the chloride at the same time 
improving the appearance of the exposed surface. In these cases, 
as well as in others where they are applied, the lint may be kept w^t 
through the day, or the solution only occasionally poured over the dress- 
ing. The chlorides are also found serviceable for fistulous openings and 
sinuses^ in fact, their use is extending over a wide field of surgery. 
On the second subject proposed for consideration little will be 
offered, being content to refer the reader to the excellent article on 
amputation, in the fourth number of the Cyclopedia of Practical Me- 
dicine and Surgery, from the pen of Professor Geddings, of Balti- 
more. This contains the opinions of nearly all authors on the sub- 
ject, and the views of the intelligent writer are similar to those of 
the Lecturer on Surgery delivered in our Medical College. Opera- 
tions which a few years ago were complicated with a multiplicity of 
instruments, and thereby requiring much time and labour, are now 
performed, with ease and celerity, with very few. I have never em- 
ployed, except in my first amputation, more than one knife, and have 
never dissected the skin for the purpose of turning it up like the cuft* 
of a coat, with the one exception, believing it now in any amputation 
useless and unnecessary. No difficulty has been experienced in se- 
curing sufficient skin to cover the stump by tiie hands of an assistant 
drawing it up, and, with the point of the amputating knife, dividing 
tlie bridles of cellular texture, even over the spine of the tibia in 
arnputation below the knee. The triple circular incision is con- 
sidered best adapted to civil practice, whether in amputation of a 
limb containing one or two bones. In the latter case, a long catlin, 
or narrow, double-edged knife, is preferred to all others; and as for 
dressing the stump, the day may not be far distant when a simple 
No. XXIX.— November, "1834. 11 



122 Eve on the Treatment of Gun-shot Wounds, 

roller bandage, and a solution of the chloride of soda or lime, will 
constitute the whole apparatus. 

The following cases may not be inappropriate to the present 
subject. A healthy boy, about fifteen years of age, had been ex- 
posed to a snow storm in last January. When discovered, his feet 
were frost-bitten, and were then very injudiciously put in warm 
water. In this state he was thrown across a horse, and, without a 
saddle, rode about thirty miles. A spontaneous separation commenced 
in a week or ten days at the ankle-joint, and, in consultation with 
the faculty, it was determined to remove both legs below the knee. 
The circular operation was performed on the left leg, and when the 
haemorrhage was secured, the right was also removed in the same 
manner; both amputated in the space of about two hours. The pa- 
tient complained more during the second amputation than the first, 
but his system suffered comparatively less from the last. It being a 
fair case to test the difference between torsion of the arteries and 
ligatures, the attempt was made on one stump to secure them with 
the forceps of Amussat and Graefe,* but owing to the difficulty of 
drawing them out, a difficulty peculiar to this amputation, and which 
the most experienced surgeons have acknowledged, it was reluctantly 
abandoned, and ligatures were applied to the vessels of each leg. 
The stumps were wetted frequently with the chloride of lime, the 
first dressing removed on the eighth day, adhesive plaster employed 
but twice in the after-treatment, and the chloride freely used. On 
the tenth day after the operation, the patient rode the distance of six 
squares of our city, and on the fourteenth, in less than two weeks, he 
went into the streets of his own accord. 

In another case of amputation, (of thigh,) also for sphacelus, un- 
der the same treatment, the patient went into the kitchen, a dis- 
tance of about twenty yards, on the twelfth day after the operation. 

If it be now considered that these operations were performed for 
the worst causes of amputation, viz. gangrene and sphacelus; and 
that of one hundred and twenty-three wounded soldiers thrown into 
a military hospital,! forty-two were cured and able to reenter the 
army, and thirty-eight were nearly well, in all eighty cases, in the space 
of two months, the dressing of whose wounds was chiefly the chlo- 
ride of lime and soda, a sufficient estimate may be formed of the uti- 
lity of the chlorides in the treatment of wounds and amputations, to 
claim some attention in the operations of surgery. 

* A description of the same forceps is claimed by Professor N. R. Smith, as 
his own invention. 

•j- That of the Sappers, at Warsaw, to which the author was attached. 
Augusta, June, 1834. 



M^Junkin's Case of Wound of the Genitals. 123 

Art. XI. Case of Wound of the Genitals. Bj James B. M'Junkin, 
of Lexington, Georgia. [Communicated bj S. H. Dickson, 
M. D. Professor of the Institutes and Practice of Medicine in the 
Medical College of the State of South Carolina.] 

On the night of the 14th of July, 1832, J. A. set. 39 years, was at- 
tacked bj a ruffian, who, aided by two negroes, seized him while 
asleep in his own bed, held him fast, and committed upon him the 
inhuman outrage which I am about to describe. 

Grasping the scrotum with his left hand, he passed his knife 
through it posteriorly, cutting it close to the body, on the right side. 
This incision, which was nearly transverse, divided the urethra and the 
greater part of the crura of the corpora cavernosa penis, leaving the an- 
terior face of the scrotum attached to the under side of the penis unhurt. 
The point of the instrument was directed inward and upward in the 
right groin, and brought out a little lower under the left. The sper- 
matic cord of the right side was severed at the same time just above 
the epididymis. A second incision was then made, two inches and 
a half in length anteriorly, meeting the former at the right of the 
root of the penis, and carried in a direction toward the superior spi- 
nous process of the right ilium; this was not deep enough to wound 
the left spermatic cord, but merely penetrated the skin. A small 
angular piece of integument was thus left undivided by the knife, on 
the left side of the penis. This was lacerated by dragging forward 
the scrotum; the skin of the penis was inverted over the glans, 
and the member denuded, and the right testis cut and torn off. The 
left testicle, now completely exposed, was retracted into the groin. 

In this situation J. A. was found by Dr. Pond and myself, who 
saw him three or four hours after the receipt of the injury. Dr. Hill 
was also subsequently associated with us in the treatment of the case. 
The patient had lost much blood, but the haemorrhage had now ceas- 
ed. He suffered much pain, which was, however, entirely relieved 
on our dividing the inverted fold of skin which lay over the sperma- 
tic cord and left testis, and in contact with the latter. The wound 
was so extensive that but a small portion could be covered by integu- 
ment. A narrow strip of lint, spread with simple cerate, was rolled 
around the denuded penis, and the parts covered and protected with 
finely carded cotton. The daily renewal of these dressings was fol- 
lowed by great pain of the testicle, which would continue some 
hours. The escape of urine at the wound in the urethra also occa- 
sioned great irritation and suffering, the patient refusing obstinately 



124 M*Junkin's Case of Wound of the Genitals. 

to submit to the introduction of a catheter or bougie, which was 
urged upon him. About the fifth day the urine found its way through 
its natural channel, the edges of the wound having coalesced; but this 
union gave way again on the occurrence of nocturnal involuntary erec- 
tions. A few days afterwards these ceased to happen, and perma- 
nent reiinion took place; but, owing to some irregularity in the man- 
ner of healing, there still remains a degree of narrowness at that 
part of the urethra, and some obstruction to the free passao;e of urine. 
On the third day there supervened much febrile excitement, with 
stupor and soreness of the abdomen; but these threatening symptoms 
disappeared under the employment of the lancet and other ordinary 
antiphlogistic remedies, and the patient was discharged in about ten 
weeks. 

In Mr. A.'s present condition, the parts exhibit the following as- 
pect. A pretty strong, smooth, elastic envelope now encloses the 
testis, supplying the place of the scrotum. This sac is destitute of hair, 
and is not at all rugous. The testicle having suppurated atone small 
spot, the sac is united to it by the cicatrix which formed on its heal- 
ing, and in consequence of this adhesion is not permitted to descend, 
but remains near the groin; a situation much exposed to accident, and 
where it is often hurt. A tense, smooth surface covers the membrum 
virile, resembling a cicatrix from a superficial burn. The mucous 
fold of the prepuce having been detached from its cutaneous prolon- 
gation, is coiled behind the glans, giving the appearance of a double 
corona or ring. Adhesions and contraction of the cellular tissue, 
especially at the posterior extremity of the penis, greatly prevent the 
erection and elongation of the organ. This is particularly obvious at 
the wound of the urethra and under the ramus of the pubis, where the 
penis appears as if tied down with a cord, occasioning irregular incur- 
vation posterior to the place of the incision. A condition resembling 
chordee also existed for some time after the parts were healed, caus- 
ing much pain and disappointing his attempts at copulation, but by 
dividing the frenum preputi, this impediment was much diminished, 
though not entirely removed. 

He now enjoys a pretty good state of health, being able to attend 
to his usual avocations, but is easily liable to a sense of fatigue in the 
lumbar region. The propensity for venereal gratification is perhaps 
as strong as ever, but the actual enjoyment is much impeded by the 
state of the organs above described. 



( 125 ) 



REVIEWS. 

Art. XII. Surgical Essays, the result of Clinical Observations made 
at Guy^s Hospital. By B. B. Cooper, F. R. S., Surgeon to Guy's 
Hospital, Lecturer on Anatomy, &c. &c. &c. London, 1833. pp. 
281, 8vo. 

1 HERE are few works possessing more interest for the profession 
than those which detail with accuracy the result of hospital practice. 
They furnish us with a clear view of the existing state of medical 
knowledge among the distinguished practitioners of the age and coun- 
try in which they are written^ they furnish the best tests for ascer- 
taining the comparative merits of conflicting doctrines, and when 
measures are exploded and their teachers no more, they remain as the 
most efficient materials in the hands of the historian of the science, 
for determining the extent of gratitude due by posterity to those who 
have truly aided the cause of humanity. In France, of late years, 
much has been done in this department; cases are detailed with the 
utmost care, and the appearances after death are described with a 
degree of minuteness that seldom leaves any thing to be desired 
which can be known in the existing state of physiology. These narra- 
tives, given by men of deserved eminence, are drawn up under the 
eyes of numerous and competent observers, and are afterwards laid 
open to the rigorous censorship of rivals who seldom leave untouch- 
ed a single debateable point either in fact or theory. The conse- 
quences of this system are obvious; French hospital practice is much 
better known abroad than that of any other country; the clinical ob- 
servations made at L'Hotel-Dieu, La Pitie, La Charite, the Hospital 
of Montpellier, &c. are mostly within our reach; the vast accessions 
of pathological knowledge thence derived are universally acknow- 
ledged, and of the value of the therapeutical treatment pursued in 
those institutions all are enabled to judge for themselves. 

Our information with regard to the medical institutions of Great 
Britain is much less complete, both as to the number of cases pub- 
lished, and as to the fulness of the detail, and we hail the appear- 
ance of this little work, by the nephew of Sir Astley Cooper, be- 
cause it in part supplies the deficiency. These essays consist essen- 
tially of a series of highly important cases, covering considerable 

11* 



126 Cooper's Surgical Essays, 

ground in some of the most interesting departments of surgeryj they 
treat of fractures, diseased joints, dislocations, and wounds of the 
abdomen. The arrangement of the work deserves decided praise. 
Each essay is preceded by some short notice of the general principles 
which should govern the treatment of the class of accidents of which 
it treats^ then follow numerous cases illustrative of those general 
principles, and to almost every case is appended some remarks with 
regard to its especial application. A collection so various in its cha- 
racter scarcely admits of analysis, and we shall attempt nothing fur- 
ther than a running commentary upon such passages as strike us in 
a novel or particularly interesting point of view. 

The author commences with some remarks '' On the Physiology of 
the Growth and Reparation of Bone,''^ Referring to his work on ana- 
tomy, previously published, for a more detailed account, (which, un- 
fortunately, is not a great deal more detailed,) of the physiology of 
the osseous tissue, he presents us with seven pages on the application 
of this subject to the treatment of fractures. We are happy to ob- 
serve that the terms table and fibre are rarely employed in this arti- 
cle, nor is much said of rings or plugs of callus in the cure of frac- 
tures. We wish not to express an opinion that these terms, when 
attended by the necessary definitions, are wholly inapplicable to the 
structure of bone, but mere names have often exerted an important in- 
fluence upon practice, and the crude and mechanical notions of the 
earlier anatomists, together with the distant and almost wild analogy 
of DuHAMEL, have associated in the minds of many the ideas of 
the tabular and fibrous arrangement of bone, with certain forms of 
inorganic or of vegetable matter, to the no small prejudice of the 
treatment of its accidents and diseases. The truly cellular struc- 
ture of all parts of the skeleton, inferred by Haller, more clearly 
described by Howship, Bichat and his followers, and experimen- 
tally proved by Scarpa, is clearly enforced by Mr. Cooper, in terms 
which at once foreclose the much vexed question as to the comparative 
importance of the periosteum, the medullary membrane, and the solid 
texture in effecting the reparation of bone in fractures. He speaks 
of the internal and external periosteum and the cellular tissue con- 
necting them collectively by the one general term periosteum, (p. 9,) 
and he considers it as enclosing the bone in the same manner in which 
the neurilema encloses the substance of a nerve, or in which the cel- 
lular sheath and its septa enclose and divide a muscle, its fibres, and 
the globules of which those fibres are composed. Nor does he ne- 
glect the facts, that the osseous tissue, thus constituted, is subject 
to all the vital laws which govern other parts, and that in cases of 



Cooper's Surgical Essays. 127 

necessity other parts and organs may be converted into periosteum, 
and contribute to the reproduction of osseous matter. 

In speaking of the gradual development of the various parts of the 
skeleton, so strictly regulated by the increasing wants of the animal — 
those first employed being always first perfected — he rejects all 
explanation founded on that metaphysical abstraction of John Hun- 
ter, 'Uhe stimulus of necessity,^^ and advances the position which, 
if memory serves us, is also advocated by Sir Astley, that the exer- 
cise of the function of a part is the proper stimulus to ossification in 
that part. It is to be feared that in assuming this position he has 
fallen into the very error he endeavored to avoid, and has trespassed 
a little beyond the barriers which should limit physical research. Be 
this as it may, we feel bound to contend against the practical direc- 
tions given in accordance with this supposed law. He recommends 
that in pseud-arthrosis, the limb should be supported by a suitable 
apparatus, and the patient directed to employ it as usual, in order 
that the shocks, the pressure, the "stimulus of exercise," should 
bring about the ossification of the callus. This is an error, even in 
the application of the law, for the effect of such treatment is evi- 
dently to cause repeated and irregular motion in a part designed to 
be constantly in a state of relative rest — to cause the fragments of a 
bone to perform functions for which nature never designed them. 
Motion in an ununited fracture can seldom be entirely prevented by 
mechanical contrivance, while the limb is exercised with any degree 
of freedom. Now, motion being the proper function of a joint, the 
law laid down, if it be general in its application, should lead us to 
infer that the treatment prescribed would tend to produce a joint, 
or, in other words, that it should diminish rather than increase the 
strength of union in a pseud-arthrosis. Experience has taught us 
that such is the effect in many cases, and if the plan prescribed does 
occasionally answer the end in view when the union has already ac- 
quired considerable firmness, the fact may be explained on different 
principles. These remarks are in strict accordance with the views 
of Mr. Cooper himself. "The elasticity of cartilage," he says, 
*'is maintained by the constant concussion produced by exertion," 
(p. 5,) and it is singular that he should not have perceived the in- 
consistency between the proposition above stated, and the practice 
which he has founded on it. The subject is an important one, and 
we may be excused perhaps for one additional remark. There is no 
rule of practice better established than that repose of the fragments 
is necessary to the union of a fracture, and this fact should never be 
lost sight of when we attempt the cure of pseud-arthrosis by producing 



128 Cooper's Surgical Essays. 

friction between the extremities of the bone. The proper degree of 
irritation once effectually produced, it is wholly unphilosophical to 
continue the painful and repeated frictions sometimes employed, 
which must retard instead of accelerating the ossification. 

The next subject taken up by Mr. Cooper is that of " Fractures in 
General," under which head he includes many particular fractures, 
a very considerable number of cases in full detail, and indulges in 
many collateral remarks on injuries of the viscera resulting from frac- 
tures of the cranium, ribs, and pelvis; the whole subject being em- 
braced in one hundred and twenty pages. Of course little space is 
allowed for dilating on general principles, and too much is frequently 
sacrificed for the sake of brevity. The cases constitute the most 
valuable part of this as of all the other essays. 

Our space compels us to pass rapidly over the surface of the work, 
confining our view to such points only as rise up in strong relief and 
enforce attention. After a very hasty outline of the distinctive marks 
of compression, concussion, inflammation, and abscess of the brain, 
occasioned by fracture of the cranium, the author says — 

*' The treatment of both concussion and compression are the same so soon as 
reaction has taken place,- which, however, is sometimes so slow in making its 
appearance, that it becomes necessary to employ stimuli, to restore the patient 
sufficiently, that he may be enabled to bear the means necessary to be employ- 
ed.'* p. 13. 

Then follows an enumeration of the vigorous antiphlogistic and con- 
comitant treatment required in the sequel, such as a purge of calo- 
mel, bleeding from the temporal artery or jugular vein, cold to the 
head, sinapisms to feet, small doses of sulphate of magnesia fre- 
quently repeated until the bowels are freely opened, and, finally, a 
blister to the scalp, if the application of cold proves inefficient. 
Mr. Cooper then demands, ''If all these means fail, under what cir- 
cumstances is the trephine to be applied?" 

This complete intermingling of accidents so dissimilar in charac- 
ter as simple concussion and simple compression of the brain, is to 
us somewhat startling. In the former, the first indications of treat- 
ment are obviously the restoration of the nervous energy, dimi- 
nished by the direct effect of the injury at the moment of the acci- 
dent, and kept up simply by the consequent weakness of the part 
without any continued mechanical cause. If the powers of nature 
are insufficient to accomplish this purpose without assistance, it may 
be proper sometimes, but certainly rarely, to call in the aid of sti- 
muli; when reaction is once established, the measures laid down, with 
the exception, perhaps, of the choice of vessels for bleeding, will be 



Cooper's Surgical Essays. 129 

approved bj every one. But in the second class of accidents, we 
have the action of a continued mechanical cause, which, in a large 
majority of cases, can only be opposed by mechanical treatment. 
If the symptoms of compression are clear and decided before reac- 
tion, what is to be gained by delay? Above all, upon what princi- 
ple can we defend the exhibition of stimuli to favour reaction under 
such circumstances? When reaction comes on, and is followed by 
urgent symptoms of compression, if the cause and location of that 
compression can be detected, every thing calls for promptitude in 
the employment of mechanical means, without waiting to ascertain 
whether the measures laid down for combating re'action will fail or 
not. We believe that the trephine is employed unnecessarily in 
many cases, but it is more than probable that the mortality following the 
operation, when imperatively demanded, is in no small degree owing 
to the tardiness of many operators. Without feeling disposed for 
a moment to charge the author with a disposition to unnecessary de- 
lay in practice, we cannot but consider the work calculated to lead 
other less experienced men into this fault. The error is almost a 
necessary consequence of the attempt to lay down in four short pages 
the distinctive characters and proper treatment of a class of acci- 
dents of the most difficult and perplexing nature, and which could 
not be properly discussed within the space devoted to the whole 
essay. 

In the remarks upon fractures of the pelvis there is nothing to ar- 
rest us particularly, but among the cases appended to this section on 
injuries of the flat bones, are several of very high interest. The first 
is a case of fracture of the basis of the cranium, accompanied by slight 
depression of a portion of bone at the posterior, inferior angle of the 
right parietal bone. The symptoms of compression were urgent. A 
fragment was removed by Hey's saw, and the remainder was elevat- 
ed. Some overlapping of the fragments continued, but all signs of 
compression disappeared, and though the patient was afterwards 
strongly threatened with inflammation of the brain and its meninges, 
he promptly recovered. This case beautifully illustrates the fact 
that a very slight depression may sometimes produce very serious 
danger, and that fractures confined almost entirely to the basis of 
the cranium, are not always beyond the reach of mechanical relief. 
The next case, and the remarks on it are intended to show that a se- 
rous discharge from the ear in injuries of the base of the brain, ren- 
ders the prognosis more favourable. The third is very singular — a 
gig wheel passed over the head of the patient, and the occipital bone 
was completely divided from its apex to the foramen magnum in a 



130 Coo^Qv'^s Surgical Essays. 

perpendicular direction! doubtless by the effect of the side-thrust of 
the lateral arches of the, cranium, constituting one of the varieties of 
contre-coup. The case terminated in death from hasmorrhage on the 
base of the brain. Passing over a case of hernia cerebri, with some 
interesting remarks which we cannot pause to analyze, we find a very 
interesting operation for a disease of the os frontis produced by seve- 
ral blows upon the part occurring at distant intervals of time, and 
giving rise to epilepsy and partial paralysis; a perfect cure was ef- 
fected by the removal of the diseased bone at least one year after the 
last accident. The inner table of the cranium was greatly and very 
unevenly thickened, and rendered like ivory in hardness. This sec- 
tion closes with two cases of fracture of the pelvis and one of dias- 
tasis of the symphysis pubis. The last case was productive of perma- 
nent irregularity of the superior anterior spinous processes of the 
ilium, but the consequent lameness was slight. 

The succeeding section treats o{ fractures of the spine. Mr. Cooper, 
in speaking of operations for elevating depressed portions of vertebra 
in cases of compression on the spinal marrow, such as have been per- 
formed by Mr. Cline and Mr. Tyrrell, but have been most strenu- 
ously opposed by Mr. Charles Bell, expresses his belief of the ge- 
neral hopelessness of such cases, but thinks the operation sometimes 
warrantable, p. 40. We do not recollect that it has ever been success- 
fully performed in America. Among the diagnostic signs of injury 
to the spinal marrow, Mr. Cooper enumerates a suffusion of the coun- 
tenance, a symptom that he has not seen mentioned by other authori- 
ties, and which he attributes to the imperfect decarbonization of the 
blood consequent upon the embarrassed state of respiration. This 
symptom has been strongly marked in several cases which we have 
seen of concussion of the spine high in the dorsal region, but which 
have terminated favourably. In similar injuries about the lower dor- 
sal and lumbar vertebra it has not been remarked, and it would be 
interesting to know if it is attendant upon fracture with depression 
in those portions of the column. Among the cases narrated is one in 
which there existed no fracture, but a laceration of the intervertebral 
substance between the fifth and sixth cervical vertebra, and death fol- 
lowed the usual train of symptoms attendant on fracture, although 
there was no lesion of the spinal marrow, and but slight marks of in- 
flammation of the dura mater. 

On. fractures of the ribs and sternum there are a few remarks and 
some interesting cases which we pass unnoticed that \ve may not 
prove too prolix, although some of the aphorisms of the author afford 
room for debate. Under the head oi fractures of the short bones, how- 



Cooper^ s Surgical Essays, 131 

ever, there is detailed one case so extraordinary that it must be men- 
tioned. It is that of a woman thrown down by a horse in full career. 

*' All the soft parts of the right side of the face were detached from the bones, 
which were most extensively fractured. The lower jaw was fractured in two 
places, the superior maxillary and palate bones were broken throug-h their pala- 
tine processes, so that the roof of the mouth fell upon the tongue, and a fissure 
extended through the body of the superior maxillary bone, into the antrum, and 
upwards into the orbit; the malar bone was broken through, so that the zigo- 
matic arch was flattened; the bones of the nose were driven in, and in fact, it 
may be said that every bone on that side of the face was fractured, and many 
comminuted." p. 60. 

In this horrible case the comminuted portions of bone were remov- 
ed, the side of the face denuded of its integuments, which are still 
preserved in the museum of Guy's, was covered with lint and kept 
cold by allowing water to fall constantly upon it. Antiphlogistic 
measures were steadily pursued, and the patient recovered " without 
a single bad symptom supervening." Numerous portions of bone, 
however, exfoliated, and protracted the cure. 

Mr. Cooper next proceeds to give some general observations on 
fractures of the long bones, and some of his remarks are highly im- 
portant. He particularly blames the unreasonable habit of most sur- 
geons in giving preference to one particular machine or position in 
the treatment of all the varieties of fracture which may occur in any 
one bone. There are indeed but few among the vast variety of con- 
trivances for the treatment of fractures that may not prove occasion- 
ally valuable, and there are certainly none which enjoy superior merit 
in all the accidents of this nature occurring in the limb or part for 
which they are designed. The surgeon who would invariably employ 
either of the modifications of the splints of White, Desault, or 
Brunninghausen, in all fractures of the thigh, whether seated just 
above the condyles, just below the trochanter minor, or in the middle 
of the shaft, would lay himself open to well-deserved censure. 

In speaking of fractures of the femur within the capsule of the hip- 
joint, he defends the peculiar views of his uncle, upon the possibility 
of bony union in such cases, against the hostile reasonings of Mr. 
Earle. We shall not enlarge upon this much-vexed subject, but 
cannot forbear the remark that the weight of the thirty years experi- 
ence of Sir Astley Cooper, great as it unquestionably is, looses a 
portion of its value, when it is remembered that the plan of treatment 
pursued by that surgeon is not at all calculated to preserve that accu- 
rate coaptation and permanent immobility of the fragments so neces- 
sary to the accomplishment of complete reiinion in any fracture, how- 



132 Coo'^QX^s Surgical Essays. 

ever situated: and although the practice of placing the limb In a 
gently-flexed position upon a bolster and pillow may be a very com- 
fortable one in hopeless cases, we cannot regard it as calculated to 
reduce the consequent lameness to a minimum even when the union 
is ligamentous. Sir Astley admits that in fractures of the neck of the 
femur unattended with complete disruption of the periosteum, bony 
union may take place; but when Mr. B. B. Cooper asserts that all the 
cases brought forward in opposition to the views of the former sur- 
geon are of this character, we conceive that he begs the question, for 
according to our memory, the remarks of M. Roux and others who 
have taken part in the controversy, by no means permit the esta- 
blishment of this fact beyond the possibility of doubt. Without at- 
tempting to pronounce a decision on the question at issue, we may 
mention that we have certainly seen an undoubted case of fracture 
within the capsule with very considerable shortening and evertion of 
the limb, and consequently with complete rupture of the periosteum, 
cured at the Pennsylvania Hospital without material lameness or per- 
ceptible extensibility of the bond of union, by means of Physick's 
modification of Desault's splint; a result hardly to be expected in 
treating any case treated without the aid of any apparatus, as is re- 
commended in the work before us. There is a very interesting case 
given by the author, in which the periosteum was so little injured 
that the coaptation of the fragments continued perfect. The limb was 
not confined, but was on the plan above noticed, and at the end of 
fifteen days when the patient died, the usual cup and ball pseud-ar- 
throsis peculiar to this fracture was already far advanced, showing 
the injurious effect of motion under the very circumstances which are 
acknowledged on all hands to admit of bony union, p. 72. 

At page seventy-three we are presented with one of the rarest ac 
cidents of the femur; namely, fracture detaching the trochanter majoi 
from the body and neck of the bone. After some time and much dif 
ficulty the character of the accident was detected by means of the 
contracted and knotty appearance of the gluteus maximus muscle, 
and coaptation was so nearly completed and maintained, by attention 
to position and the application of compresses and bandage, that scarce 
any trace of lameness remained. The case is one of very high inter- 
est, and reflects great credit on the surgeon. We are the more 
anxious to acknowledge this, because we are now about to enter 
upon the description of accidents touching the mechanical treatment 
of which there can be little accordance between the English and Ame- 
rican schools of surgery. Tiie influence of the prejudice of Pott in 
favour of an undue dependence on mere position in fractures, and a 



Cooper's Surgical Essays. 133 

certain degree of national antipathy to French surgery, have thrown 
the profession in Great Britain far behind the rest of the world, in 
the management of fractures requiring continued extension, and 
though both these causes have almost ceased to operate within the 
last i'ew years, long-continued habit renders the necessary reform but 
too gradual in its progress. 

"When the fracture is very oblique," says Mr. Cooper, when speaking of 
fractures about the middle of the shaft of the femur, " it almost invariably re- 
quires the straight and continued extended position to maintain the fractured ex- 
tremities of the bone in apposition; but on the contrary, when the fracture is 
very transverse, the surface of the upper fractured portion offers a sufficient 
and convenient obstacle to the lower portion being drawn upwards and in- 
wards by the muscle." p. 78. 

To the first clause of this sentence almost every American surgeon 
will yield a ready assent, and it is only to be regretted that the re- 
quisition is not so strictly attended to, as might be thought desirable, 
even in the cases afterwards detailed. But with regard to the second 
clause we cannot omit some remarks, in which we are compelled to 
disagree not only with Mr. C. but with the whole weight of systematic 
authority. In the first place then we do not believe that it is pos- 
sible to determine, except perhaps in cases of great emaciation, when 
a fracture in the middle of the shaft of the femur is really transverse; 
unless it is assumed that the absence of longitudinal deformity is a 
proof of the transverse direction of the fissure, and the presence of 
such deformity an equally certain indication of its obliquity; neither 
of which positions is tenable. A limb may retain its full length, after 
very oblique fracture of the shaft of the femur, in consequence of the 
feeble action of the muscles produced by the collapse in severe in- 
juries, as we have seen in a case in which the near approach of the 
superior fragments to the skin, consequent upon extensive laceration 
of the muscles, placed the character of the accident beyond a doubt. 
We have also met with a case of complete comminution of the femur 
from within three inches of the trochanter minor to a point about 
equally distant from the condyles, unattended with any shortening 
of the limb. In neither of the cases was it possible to account for 
the absence of overlapping by supposing the soft parts to have lost 
their contractile power permanently, for they terminated favourably 
without lameness. 

In the second place, supposing the fracture to present every symp- 
tom of a transverse direction, nay, even granting that it is absolutely 
proved to be so, there is no efficient protection against longitudinal 
deformity, without the aid of mechanical measures. If no attempt is 
No. XXIX.— November, 1834. 12 



134 Cooper^ s Surgical Essai/s. 

made to retain the proper direction and length of the limb, by other 
means than simply laying it in a flexed position, or placing it on an 
inclined plane, the bone is constantly liable to lateral derangement 
from slight changes of posture, or from unequal or convulsive action 
of the muscles, under which forces the ends of the fragments are ren- 
dered relatively oblique, although they continue perpendicular to the 
axes of the corresponding fragments. Again, supposing the parallel- 
ism of the extremities to be steadily preserved, the constant, though 
slight rotations of the limb Mhich cannot be prevented, have a ten- 
dency to twist the fractured surfaces in one direction or another, and 
may very readily destroy their apposition. We have indeed seen 
cases of temporary interlocking of the fragments, preventing not only 
the shortening of the limb, but even the eversion of the toes, and it 
is evident that this may occur as well in oblique as in transverse 
fractures. In nine cases out of ten, the mere attempt to determine 
the direction of the solution of continuity would destroy the corres- 
pondence between the ends of the bone in transverse fractures. We 
have carefully observed at least sixty cases of fractures of the shaft 
of the femur, occurring during the last fourteen years, with reference 
to this particular question, and in no instance have we noticed a case 
which did not sooner or later require permanent extension and counter- 
extension. Even supposing the general impression on this subject to 
be correct, a moment's thought would show that the extended position 
is peculiarly adapted to transverse fractures, on the very principle 
laid down by Mr. Cooper himself. Here, on the hypothesis, there 
would be a disadvantage in the double-flexed position, for the appo- 
sition of the fragments effectually resisting the disposition to shorten- 
ing, the whole force of the muscular contractions tend to increase the 
pressure which he regards as so favourable to ossification, and surely 
there can be no more certain means of preventing every other species 
of deformity than the application of inextensible extending, and 
counter-extending bands, without force, but with sufficient ftrmness 
to prevent all changes in the direction of the limb. This distinction 
in practice between transverse and oblique fractures of the femur, 
has been copied from work to work without sufficient examination, 
and is calculated to deceive the inexperienced. We can see no ad- 
vantage in the knowledge of the direction of the fracture; the proper 
rule of treatment is a plain one. If the limb retain its length, it 
should be prevented from contracting; if it be shortened, it should be 
brought down to its correct dimensions, and both these ends are best 
accomplished by placing it in the straight position. In fractures of 
the tibia, where the outline of the bone is easily felt, and its dimen- 
sions are greater, the distinction is much more important. 



Cooper's Surgical Essays. 135 

Among the curious cases of fractured thigh narrated in this section, 
there is one of threatened pseud-arthrosis, in which the propriety of 
excising the extremities of the bone was discussed in consultation, 
and its performance submitted to the judgment of the patient. Pres- 
sure on the seat of fracture was twice ineffectually made by means of 
a leather strap and buckles! and was finally relinquished in conse- 
quence of the usual inconveniences of partial ligatures upon a limb. 
What most astonishes us in this case is the proposal of so terrible and 
doubtful an operation, before the trial of frictions of the fragments on 
each other, stimulation of the neighbouring parts, seton, or any of 
the now well-known and often highly successful plans of treatment 
for pseud-arthrosis! It is an instance of the injurious effect of the 
application of hypothetical ideas to practice in preference to the re- 
sults of actual observation. More than eighteen months after the 
accident, the union being still incomplete, the patient was ordered to 
use the limb, in order to effect " perfect consolidation, by inducing 
earthy deposition through the natural stimulus to its growth; namely, 
motion and pressure P"^ The case is still pending, and the result, con- 
sequently, can only be inferred. 

In the remaining details with regard to fractures of the inferior and 
superior extremities, we meet with much deserving of notice, and the 
cases possess considerable interest. The remarks on the pathology 
and diagnosis are often important and valuable, and the mechanical 
treatment throughout seems to be regulated upon principles similar 
to those laid down by Sir Astley Cooper in his great work on Frac- 
tures and Dislocations; they differ widely from those most popular 
on this side the atlantic. 

The essay on diseases of the joints occupies thirty-three pages, and 
contains, in addition to a very rapid, but clear outline of pathological 
principles, a number of cases in illustration of them. They are va- 
luable, but offer too little novelty to detain us. That on dislocations 
is extended to ninety-three pages, and contains short notices, seria- 
tim, of most possible accidents of this character. The general re- 
marks in each section of this essay are avowedly quoted, chiefly from 
the great work of Sir A. Cooper on the same subject, which is al- 
ready so well known to the profession that it is needless to attempt 
an analysis. The cases are numerous, curious, and interspersed with 
many pertinent commentaries, and the whole presents a general view 
of the opinions of the eminent surgeon just mentioned, which cannot 
but prove desirable to those who wish a compendious view of those 
opinions with novel illustrations, but without the numerous and costly 
plates of the original. 



136 Cooper's Surgical Essays. 

The work closes with a very short essay on wounds and injuries of 
the abdomen, chiefly important for the cases of rupture of 'the abdo- 
minal viscera without any wound of the parietes. In one most sin- 
gular instance of this kind the kidney was extensively lacerated 
without the occurrence of any fracture or external wound, and the 
case proved fatal from the internal haemorrhage which followed. Mr. 
Cooper observes that the collapse which follows laceration of a bowel 
is sometimes absent immediately after the accident, but appears im- 
mediately upon the extravasation of faecal matter, of which the col- 
lapse is strongly diagnostic in such cases. Several instances are men- 
tioned in support of this position, and one among others, in which an 
intestine was ruptured by a kick, in a scrotal hernial sac. Collapse 
and death from extravasation followed the reduction of the hernia. 
Upon this observation he founds this rule — 

"A person having received an injury of the abdomen attended with symp- 
toms of prostration, at the same time having" a hernial tumour, that the contents 
of that tumour are not to be returned into the abdominal cavity; but that as 
soon as the reaction has taken place the strict antiphlogistic plan is to be adopt- 
ed, leaving it to nature to repair the injury any viscus may have sustained; for 
should the contents of the hernial sack be injured, and even the intestine lace- 
rated, as in this case, nature would immediately shut up the hernial from the 
general cavity of the abdomen, and the contents of the bowel would be poured 
out only into the sac, indicated by the sudden swelling of the part, and the relief 
experienced by the evacuation. A cure is then to be effected by opening the 
tumour, discharging its contents, and treating it as an artificial anus." p. 277. 

The greatest defect in this essay is the light manner in which the 
contusions of the abdomen not complicated with rupture or laceration 
of the viscera are noticed. Mr. C. acknowledges that they are some- 
times productive of collapse, but remarks that they almost always re- 
cover under proper depletion in anticipation of inflammation^ a mea- 
sure of which he directs adoption immediately on the subsidence of 
the stage of depression, when the surface becomes warm^ suggesting 
that stimulants may be given in some cases to bring about this con- 
dition. " No detail has been preserved of these usually trivial acci- 
dents." Now, there are no cases more perplexing to the surgeon, or 
more deserving of close examination and research, than these very 
accidents. How often do we see patients who have been buried un- 
der masses of earth, or whose abdomens have been compressed by 
great weights, dying in collapse without any distinct marks of peri- 
toneal or other inflammation, even though they survive forty-eight 
hours or longer; and how often on the contrary do severe blows, act- 
ing on a smaller portion of the parietes, but with no obvious lesion 



ChomeVs Clinical Lectures on Typhoid Fever. 137 

of any viscus, occasion death in half that time, from collapse equally 
profound, yet causing the intestines to become agglutinated and the 
abdominal cavity filled with masses and flocculi of coagulated lymph 1 
Can stimuli be equally proper under circumstances so widely differ- 
ent? If not, how are we to perfect our diagnosis? We do not pre- 
sume to answer either of these questions, but the subject is much in 
want of further elucidation. It should always be borne in mind in 
the treatment of surgical injuries, that collapse may be produced 
either by such general mischief to the whole nervous system as may 
directly oppress all the vital operations, or from such an excessive ir- 
ritation as may concentrate, as it were, the whole vital energy of the 
system upon a point. 

In taking leave of the work of Mr. Cooper, we cannot but express 
our regret at its want of clearness in style. With regard to matter, 
much might have been added in the way of praise and dissent, 
but M'e sincerely hope that other occasions will be offered from 
the same quarter hereafter, and that the clinical observations of 
London hospital practice may continue to be made public from time 
to time in a manner equally clear and impressive. One word to those 
who enjoy similar advantages in our own institutions. Why are the 
results of the practice of our own hospitals confined almost within 
the limits of their walls? The work of Mr. Cooper, while it informs 
us how much we might communicate with advantage to the profes- 
sion, furnishes us in its arrangement with an excellent model for 
imitation. R. C. 



Art. XIII. Legons de Clinique Medicale faites a PHotel-Dieu de 
Paris, par le Professeur A. F. Chomel, Recueillies et Publiees 
sous ses yeux, par J. L. Genest, D. M. P., Ancien chef de Cli- 
nique Medicale de PHotel-Dieu, &c. (Fievre Typhoide.) 8vo, 
pp. 548. Paris, 1834. 

Clinical Lectures on Typhoid Fever, delivered at the Hotel-Dieu of 
Paris. By Professor Chomel, Collected and Published under his 
Inspection, by J. L. Genest, M. D. &c. 

U NDER the denomination typhoid, Professor Chomel includes all 
the severe grades of continued fever, in consequence of the presumed 
analogy which exists between their general phenomena and those of 
the typhus fever of camps. However dissimilar, he remarks, the se- 
veral varieties of continued fever may appear in many of their symp- 

12* 



138 ChomePs Clinical Lectures on Typhoid Fever. 

toms, yet in their general phenomena and progress they present an 
identity of character; which identity is still further established by the 
lesions discovered after death in the intestinal canal. These lesions, 
which consist in a morbid state of the glands of Peyer and Brunner, 
conjoined ordinarily with tumefaction and other diseased conditions 
of the mesenteric glands, are present, according to our author, in no 
other affection, while they are almost invariably met with in the fever 
under consideration, whatever may be the form which it assumes, 
whether inflammatory, bilious, mucous, adynamic, ataxic, or nervous. 
All other pathological lesions detected in typhoid fever, of whatever 
character, or wherever seated, M. Chomel views as merely accidental 
complications, the presence of which may, it is true, modify to a cer- 
tain extent the symptoms of the case, but their absence does not in 
the least influence the peculiar characteristics of the disease. It will 
be perceived, therefore, that the typhoid fever of our author corres- 
ponds very nearly with the enter o-mesenteric fever of Petit and 
Serres, the exantheme intestinal of M. Andral, the dothinenteriie 
of M. Bretonneau, and the follicular enteritis of various other 
writers. 

The following summary of the author's description of the lesions 
of the intestinal follicles discoverable after death from typhoid fever, 
will enable the reader to form a judgment of their character. 

The first alteration which the follicles of the intestinal mucous 
membrane experience is their tumefaction, which is occasioned by 
the formation, beneath the mucous membrane, of a yellowish-white 
matter, somewhat friable, and which gives to the cluster of follicles 
constituting the glands of Peyer the appearance of a patch, and to 
the isolated follicles or glands of Brunner the form of a large pimple 
of a colour more or less white, and which many pathologists have im- 
properly denominated a pustule. These changes, which do not preserve 
very decidedly their characteristics beyond the twelfth or fifteenth 
day from the commencement of the disease, are succeeded, in the ma- 
jority of cases, by ulceration. This commences sometimes at the mu- 
cous membrane and gains gradually the white matter of the tumid 
follicles, and in other cases it begins by a softening of the latter, 
which becomes detached from the parts with which it is in contact, 
and produces subsequently the destruction of the mucous membrane. 
These morbid alterations commence almost invariably in those folli- 
cles which are nearest to the ileo-ccecal valve. About the eighth, 
fifteenth, or twentieth day of the disease, we find, in a few instances, 
either at the surface of the tumefied patches, or what is more fre- 
quently the case, upon the glands of Peyer, the softened mucous 



ChomeVs Clinical Lectures on Typhoid Fever, 139 

membrane, of a colour more or less intense, detached from the sub- 
jacent tissues and presenting numerous perforations, which are in 
fact the orifices of the follicles greatly enlarged. In proportion as 
the tumefied patches or their remains gradually disappear, in conse- 
quence of the progress of ulceration, or by a species of gangrene, the 
edges of the ulcers which are in consequence produced, become flat- 
tened, approach each other from below, and present a condition very 
favourable to cicatrization, or they acquire, on the contrary, a mor- 
bid thickening, caused by the hypertrophy of the sub-mucous and 
muscular tissues, and present an appearance which has considerable 
analogy with that of a tissue in a state of scirrhous. The ulceration 
of the tumefied patches extends not only in breadth but also in depth, 
and invades successively the sub-mucous and muscular tissues, and 
in some cases even the peritoneum, causing a perforation of the intes- 
tine, which may also be produced by sphacelus of the peritoneal coat. 
In the most favourable cases cicatrization of the ulcers takes place. Ul- 
ceration does not occur in all the tumefied patches; there are a cer- 
tain number which return to the normal state, without ulcerating, by 
a species of resolution, the eftused matter being absorbed. At the 
same time many of the patches present a dark blue or slaty colcur^ 
which colour has also been observed in subjects that have died of 
other diseases than typhoid fever, or a long time after having been af- 
fected with this disease. The foregoing alterations in the condition 
of the mucous follicles of the intestines M. Chomel declares to be pe- 
culiar to typhoid fever; in almost all cases of which they are to be 
met with. Of forty cases of the disease which terminated in death at 
the Hotel-Dieu, within five years, in every instance they were de- 
tected to a greater or less extent, and in a more or less advanced 
stage. 

Notwithstanding, however, our author insists upon the invariable 
presence of the above lesions of the intestinal mucous follicles, and 
of tumefaction and other morbid changes in the mesenteric glands in 
typhoid fever, viewing them, in fact, as an essential characteristic of 
the disease, he does not consider them as the cause of the symptoms 
during life, with the exception perhaps, of the diarrhoea, pain of the 
abdomen, and gurgling noise produced when pressure is made with 
the hand upon the lower portion of the abdomen, especially upon the 
right iliac region. Nor does M. Chomel consider them to have any 
influence whatever upon the violence or progress of the disease. He 
sets them down as effects merely of the general morbid condition un- 
der which the patient labours. 

" The lesions," he remarks, " of the intestinal mucous follicles and of the 



140 ChomePs Clinical Lectures on Typhoid Fever, 

mesenteric glands do not present the same degree of development in every case. 
In some, all the grouped and isolated follicles are tumefied or ulcerated, in 
others there are only a certain number which are altered in structure; twenty 
for example in some cases, in others fifteen, and in others only five, three, two 
or even one, and that sometimes only partially. Now if all the symptoms of the 
disease and its severity depended upon the lesion of the follicles, there would 
certainly exist a relation between tlie phenomena during life and the extent of 
the lesions discovered after death; while also the violence and danger of the 
case would be in direct proportion with the number of the follicles affected, 
and the extent of the alteration in each. But it is shown by accurate observa- 
tions that, in one patient the disease will show itself with symptoms of the 
utmost severity, and after death but a very small number of follicles will be 
found affected; while in another patient, the typhoid symptoms will present but 
a very moderate degree of violence, but should he die in consequence of the ac- 
cidental occurrence of another disease, we shall find the intestinal follicles pre- 
senting the most extensive lesions." 

Among the accidental lesions, or those which appertain less espe- 
cially to typhoid fever, M. Chomel enumerates ulcerations of the 
tongue, fauces and oesophagus. Redness of the mucous coat of the 
stomach varying in intensity in different cases^ but which the author 
maintains we have no evidence to attribute positively to inflammation. 
Softening of the mucous membrane at the great extremity of the sto- 
machj in a few cases softening of the greater portion of the mucous 
coat, and still more rarely softening of all the coats. Softening of 
the gastric mucous membrane to a greater or less extent was present 
in fourteen out of forty-two cases. According to M. Chomel it is not 
met with more frequently after death from typhoid fever than in sub- 
jects who die of other diseases. Occasionally thickening or thinning of 
the mucous membrane was detected. In the intestines the duodenum 
and jejunum, presented in the majority of cases, a deeper red colour 
than the remaining portion of the intestinal tube . This redness was mix- 
ed with a shade of yellow, which diminished ordinarily as we proceed 
from the jejunum, but which in some cases continued even to the ileo- 
coecal valve. The ileum was frequently increased in redness, some- 
times throughout all its coats, presenting on the external surface 
numerous arborescences. Sometimes the redness was confined to 
the mucous coatj in this latter case the free edge of the valvulae 
conniventes were occasionally of a very bright red. They appeared as 
though they had been stained by red blood coming from their vessels, 
but the redness was not removed by washing the parts in water. More 
frequently the redness of the ileum was disposed in zones, which were 
separated from each other by zones of equal breadth where the three 
coats were remarkably pale. The parts where the rediiess was the most 



ChomePs Clinical Lectures on Typhoid Fever, 141 

decided were in these cases ordinariljin those portions of the intestinal 
circumvolutions which occupied a depending situation, relatively to 
such as preserved a pale tint. In a considerable number of cases the 
half or two-thirds of the ileum were decidedly increased in redness, 
while the residue of the intestine remained comparatively pale; or- 
dinarily the red portion was situated in the pelvis, while the paler re- 
mained in the abdomen. The increased redness of the mucous mem- 
brane was not more decided in the neighbourhood of the diseased fol- 
licles, than at a distance from them. The colour of the mucous coat 
of the large intestines offered fewer varieties than that of the small. 
It rarely presented any considerable redness throughout its whole ex- 
tent; very often it was found covered with red spots, varying in size, 
which were sometimes of so deep a colour as to resemble ecchymoses. 
It is but seldom, according to our author, that that portion of the 
mucous coat of the intestines which separates the clustered or isolat- 
ed follicles, is softened in so great a degree as is found to be the case 
in the stomach. In three out of forty-two cases the mucous coat of 
the small intestines was found reduced to the consistency of a layer of 
gum Arabic. In one case the mucous coat of the ileum was softened at 
some points, but not at those parts where the redness was the most 
vivid. In another the mucous coat of all the upper portion of the 
same intestine was reduced to the consistency of mucilage. 

" We may conclude," remarks M. Chomel, from a comparison of the symp- 
toms during" life with the lesions discovered after death, '* that the different pa- 
thological conditions of the stomach, whether the state of injection, softening ©? 
the slaty colour which it sometimes presents, or finally the thickening' of its 
mucous coat in subjects who have died whilst labouring- under typhoid fever^ 
do not manifest themselves constantly by any particular symptom previously to 
death, and that it is impossible to say from the symptoms of the case with cei- 
tainly, whether any appreciable alteration exists in the stomach, or what is the 
nature of such alteration." 

The same, he adds, may likewise be said in regard to the lesions dis- 
covered in the intestinal tube. 

In several instances a sanguineous infiltration of the intestinal 
mucous membrane was met with. In these cases the mucous mem- 
brane was double or even triple its ordinary thickness, and offered a very 
peculiar aspect, resembling somewhat a layer of jelly of a black, red 
or only rosy colour; having also its shining and tremulous appearance^ 
If over the portions thus infiltrated with blood, the handle of a scalpel 
was passed with a moderate degree of force, from the pores of the mem- 
brane there was found to issue a fluid more or less red, and some- 
times in considerable quantity, the membrane at the same time re- 



142 ChomePs Clinical Lectures on Typhoid Fever, 

turning to its natural thickness, and sometimes even to its ordinary hue. 
The parts thus engorged varied in extent in different cases from four 
inches to two or three feet. The redness was always continuous, and 
occupied the whole area of the intestine, the portions the most in- 
ferior presenting no difference from those situated above. In those 
instances in which the fluid infiltrated was of a light red colour and 
transparent, by the naked eye numerous small vessels of a deeper co- 
lour could be discovered permeating the whole of the aff'ected tissue, 
the extremities of which would appear to terminate on the surface of 
the mucous coat. Of the seven subjects affected with typhoid fever, 
in whom after death the above lesions was discovered, two had ex- 
perienced intestinal haemorrhages, a third had discharged blood by 
vomiting; in two others the small intestines contained a quantity of 
blood, and the other two, so far as could be ascertained from the ob- 
servations made at the hospital, had been unaffected with hasmorrhage. 

After the mucous follicles of the intestines, the spleen, according 
to M. Chomel, is the organ most frequently found in a morbid state 
in those who die of typhoid fever. In almost every case the spleen 
was increased in size. Sometimes the increase was inconsidera- 
ble, at others the organ was double, triple, or even quadruple 
its ordinary size. Although the augmentation in size was gene- 
rally most considerable in those subjects who died during the most 
acute period of the disease, before, namely, the twentieth or twenty- 
fifth day, yet no very great difference was observed between the bulk 
of the organ in those who sank during the first days of the disease 
and those who survived a somewhat longer period. Subsequently to 
the twenty-fifth day the size of the organ was in general reduced. 
To this, however, there were many exceptions. In a certain number 
of cases the spleen was not only increased in size, but also singularly 
diminished in density. Ten times it was found more or less softened, 
and thrice it was completely diffluent. In other instances, in place 
of being softened, it presented a degree of firmness that it rarely 
possesses during a state of health. This was generally found to be 
the case after the twentieth day, when the other organs were regaining 
their normal condition. The colour of the spleen was variously changed ; 
no one, however, of these morbid states of the spleen is connected, 
we are told, with any particular symptom or form of typhoid fever. 

Of the liver, the only morbid state which was observed after ty- 
phoid fever, sufficiently often to demand particular attention, was a 
softening, more or less considerable. 

" The softening- of the liver as well as the spleen," remarks M. C. " was ordi- 
narily accompanied with a softening of other organs and even of those which 



Chomel's Clinical Lectures on Typhoid Fever, 143 

are the most important to life. This fact proves that the softening was not the 
result of inflammation; for it v/ould be difficult to conceive how so many im- 
portant organs could at the same time be inflamed without life being instantly 
extinguished. We also perceive, in part at least, the reason why the lesions 
alluded to are not manifested during life by any particular symptom." 

The changes observed in the state of the blood in those who die 
from tjphoid fever are, according to our author, sufficiently distinct 
from those we observe ordinarily after other diseases to merit parti- 
cular attention. More frequently the blood was black and completely 
diffluent; very rarely small fibrinous coagulawere found in the heart, 
and still more rarely in the blood-vessels. In other cases, the blood, 
without being completely diffluent, was found in the heart or aorta in 
the form of coagula of a black colour, and very different from those 
we meet with in subjects who have died of other acute aftections. 

*' The absence of fibrine in the blood of those subjects who die of typhoid 
fever is the most striking, and perhaps the most important modification which 
that fluid presents; the same has been observed in regard to the blood drawn 
from a vein during the life of the patients. 

•'Another alteration observed, but more rarely, in the blood of subjects who 
have died of typhoid fever, is the development of a quantity, more or less con- 
siderable, of gas in the interior of the blood-vessels, especially the veins. In some 
subjects, if we lay bare a large vein, at a part where it does not receive branchesj 
we can often observe bubbles of gas, which may be made to move along the 
vessels, and are perceptible through its thin and almost transparent coats." 

In these cases, it is remarked, the blood presents other traces of 
commencing decomposition. Often it resembles coffee-grounds floating 
in an oily fluid. 

In numerous cases the consistency of the parietes of the heart was 
found decidedly diminished; in none did it appear to be increased. 
Sometimes the softening was to so great an extent that the muscular 
tissue of the organ broke down between the fingers with the greatest 
ease. In general this diminution in the consistency of the tissues of 
the heart coincided with the softening of the other organs. In other 
cases in which the diminished consistency of the muscles of the heart 
was not so evident, the organ was found in so flaccid a state that its 
parietes sunk together similar to those of a simple membranous bag. 

In thirty cases in which the condition of the heart was noted with 
care, in four there was slight softening and discoloration of all the 
tissues, in three softening and discoloration of the left ventricle 
only, in one discoloration without softening, in seven flaccidity 
without softening, and in fifteen the heart was in a normal condition. 
The colour of the lining membrane of the heart was sometimes of a 
brighter red than natural, in others the redness was more deep or even 



144 ChomePs Clinical Lectures on Typhoid Fever, 

livid more frequently, especially when accompanied with softening 
of the muscular tissue the lining membrane was almost entirely des- 
titute of colour. In no instance did this membrane present the cha- 
racters proper to inflammation; thus it was never found covered with 
pus or false membranes, nor presenting a granular appearance. In 
some cases the internal membrane of the heart alone presented an 
increase of redness, while that of the aorta and great arterial trunks 
preserved its normal hue. Frequently the internal membrane of the 
aorta was of a morbid redness, but the characters of this redness, ac- 
cording to M. C, were far from indicating it to have been the eifect 
of inflammation. In no instance did it result from an injection of the 
capillaries, but seemed rather to be owing to the imbibition of the 
more fluid portion of the blood. It has almost always appeared to the 
author to be connected with the putridity of the blood which was found 
in contact with the membrane. 

With respect to the lesions observed in the respiratory apparatus, 
the author enumerates oedema of the glottis, and occasionally ulcera- 
tion laying bare the cartilages. The larynx, he remarks, was also oc- 
casional the seat of ulceration. The morbid appearances met with 
most constantly in the lungs were those which occur just before death, 
such as an engorgement at their posterior and inferior portions. In a 
certain number of cases this engorgement was accompanied with a de- 
gree of softening sufficient to allow of the finger penetrating with 
ease the tissues of the organ. In a few instances the lungs were affect- 
ed with genuine pneumonia; sometimes the pneumonia was confined 
to some of the lobules of one lung, accompanied most frequently 
with suppuration. In other cases the pneumonia occupied an entire 
lobe; in this case the patient generally sunk before the occurrence 
of suppuration. 

" Sometimes we observed an emphysematous or oedematous condition of dif- 
ferent parts of the lungs, and finally in other instances a pleuritic effusion more 
or less considerable. In forty-two cases, all, with the exception often, presented 
a morbid condition of the lungs. In eighteen there existed engorgement alone 
or connected with softening; in three hepatization in the first degree; in two 
hepatization in the second degree and on a single side; in three lobular pneu- 
monia; in two emphysema; in two oedema; and in two pleuritic eff'usion. These 
different alterations, however, remarks M. C. have but a very remote con- 
nexion with the typhoid fever, and seem to us to depend rather upon the state 
of debility in which the patient is sunk, which produces in him a greater sus- 
ceptibility to morbific causes. In fact, this species of complication is never met 
with when the patient dies a few days after the attack of fever, but only at a 
more advanced period.'* 

The morbid alterations discovered in the brain after death from 



ChomePs Clinical Lectures on Typhoid Fever. 145 

typhoid fever, exert as little influence, according to M. Chomel, in 
the production of the phenomena of the disease, as those detected in 
the other organs. 

The delirium, he remarks, which so commonly accompanies ty- 
phoid fever, is the most frequently unconnected with any appreciable 
lesion of the brain. We find, it is true, in a certain number of cases, 
two conditions of that organ which present a decided deviation from 
what is commonly considered its normal state; namely, the oedema 
of its membranes, and an appearance of red points throughout its sub- 
stance when an incision is made into it. 

** But," he adds, " as these conditions occurred as frequently in those cases in 
which no disorder of the intellectual functions was present as in those where 
this disorder existed, and as they are as frequent in other diseases as they are 
in the disease under consideration, we can draw from them no positive de- 
duction.*' 

The serousinfiltrationofthepiamaterandarachnoides occupied most 
generally those parts which cover the hemispheres, but occasionally 
he found it also towards the basis of the brain. Sometimes there was a 
decided congestion of those membranes, but in examining with atten- 
tion it was found to be ordinarily confined to the venous tissue, the 
great trunks of which were greatly distended. In a few instances 
the congestion was so great as to produce an effusion of blood into 
the tissue of the membranes to a considerable extent. 

The brain was often slightly softened throughout; an alteration which 
M. Chomel conceives to be connected with the softening of the other 
organs so frequent in the disease before us. Finally, in some cases 
the brain appeared to be increased in density, but this alteration, if it 
be such, remarks the author, like the others was not connected with 
any particular period of the disease. Of thirty-eight cases in which 
the state of the brain was carefully examined, four presented injec- 
tion of the meninges; seven oedema of the meninges; sis slight gene- 
ral softenino-; twelve serous effusion into the ventricles, varvin"; from 
a tea-spoonful to a table-spoonful; five presented bloody points 
throughout the cerebral substance; two abnormal density, and in fif- 
teen there was no alteration whatever. 

From the foregoing summary of Professor Chomel's autopsical in- 
vestigations of typhoid fever, it will be perceived that he considers 
the whole of the lesions discovered after death to be altogether un- 
important, either in explaining the causes concerned in the produc- 
tion of the disease, the character of its successive phenomena, or its 
mildness or malignity. Typhoid fever he conceives to be a certain 

No. XXIX.— November, 1834. 13 



146 Chomel's Clinical Lectures on Typhoid Fever, 

morbid state of the whole organism, dependant probably upon an al- 
tered condition of the fluids^ the symptoms by which it is manifested 
being " the expression of the influence of the general morbid condi- 
tion upon the entire economy and resulting from the disorder of the 
principal functions to which the disease gives rise;" in other words, 
that they appertain rather to the typhoid fever itself than to any or- 
ganic lesion. The morbid appearances so commonly detected after 
death, M. Chomel seems to think, are produced secondarily by the 
action of the disease upon the organs. He admits, however, that it is 
difficult to explain by what mysterious influence many of these lesions, 
so different in their character, are produced in the present form of 
fever. All this may perhaps be very good pathology, but it appears 
to us to be any thing but clear and satisfactory. 

Towards the close of the work M. Chomel enters into a series of 
arguments to prove the difference which exists between a primitive 
and local inflammation and one that is secondary and disseminated. 
According to his definition, an inflammation is primitive and local 
"when it alone constitutes the disease, and occupies, continuously, a 
surface of greater or less extent — it is secondary and disseminated 
when it is the result of a morbid condition of the entire organism, and 
occurs at a number of different points between which the parts are in 
a normal condition. We believe it to be unnecessary to enter into 
any examination of our author's obsolete views on these particular 
points. His reasoning in support of them is altogether vague and in- 
conclusive, and his illustrations, so far from strengthening his pre- 
mises, are either mere assumptions, or at best require further evi- 
dence to establish their correctness. 

As the terms typhus and typhoid are in themselves extremely in- 
definite, and have been applied to a great variety of diseases by dif- 
ferent writers, many of which diseases have been shown to be very 
distinct in their pathological character, it is all-important to ascer- 
tain precisely in every case what are the morbid phenomena which 
they are employed to designate. Hence our author has, in the com- 
mencement of the work before us, very properly presented an admira- 
ble history of the disease denominated by him typhoid fever, in which 
the character and succession of the general symptoms are described 
with great minuteness and clearness. The great length of this pre- 
cludes the possibility of our translating it entire, and no abstract of 
it would convey a distinct idea of the disease which it is intended to 
delineate. We prefer, therefore, to select the more prominent of the 
author's diagnoses, which will present, with tolerable accuracy, the 
general characteristics of what he terms typhoid fever. 



ChomePs Clinical Lectures on Typhoid Fever. 147 

" During- the first da3'Sof the disease," remarks M. Chomel, " it Is often im- 
possible to determine positively whether it be typhoid fever or some one of 
those affections with which it more or less corresponds. In a number of cases, 
however, even from the very commencement, we may suspect the nature of 
the malady; thus, if it attack suddenly; if to the decided febrile symptoms there 
is joined, without our being- able trace it to any appreciable cause, a permanent 
pain of the head with vertigo and a staggering- g-ait, and this in a subject at the 
particular period of life M^e have indicated.* Particularly if he has inhabited 
but for a short time a large city, and if there is reason to believe that he has not 
already suffered from the disease,! in all probability he is labouring- under ty- 
phoid fever. This may be decided with more certainty if, in addition to the first 
symptoms, there occur successively, after the second or third day, some one of 
the other symptoms most common in the disease, such as purging, prostration 
of strength, commencing stupor, and a discharge of blood from the nose. 

** One of the most important phenomena of the typhoid malady is the dura- 
tion of the fever. When febrile symptoms that we cannot refer to any appre- 
ciable lesion are prolonged beyond a certain period, eight or ten days, for ex- 
ample, we have serious cause for suspecting that they are connected with dis- 
ease of the g-lands of Peyer. 

'* During the middle period, most frequently from the sixth to the twelfth 
day of the disease, we see appear certain symptoms which, in the greater num- 
ber of cases, should leave no doubt in regard to the diag-nosis, namely, mete- 
orism of the abdomen, the typhoid eruption, i: stupor, which in the majority of 
cases is considerable, epistaxis, and haemorrhages from the bowels. 

** At an advanced period of the disease it is still more rare that any doubt can 
exist as to the nature of the disease. If the phenomena proper to the first or 
second periods have been uncertain, this will not be the case with those which 
mark the third stage. Haemorrhages from the intestines, the ulcerations which oc- 
cur upon different parts of the bod}^ involuntary discharges from the bowels, the 
strongly-marked symptoms of adynamia, occur successively, and fix with cer- 
tainty our diagnosis." 

The disease which at first view, we are told, would appear to be 
the most readily confounded with typhoid fever is enteritis. Ente- 
ritis, however, is observed in subjects of every age, is the result of 

* According to M. Chomel, typhoid fever attacks individuals between the 
age of eighteen and thirty, when the strength of the body is the most fully de- 
veloped; it is rarely observed after forty; and no case has yet been recorded in 
which the disease has attacked an individual aged over fifty-five years. 

t M. Chomel believes that typhoid fever ordinarily occurs but once in the 
same individual, 

t Small red spots, which disappear upon pressure, about a half a line to two 
lines in diameter, of a circular form, and but a little or not at all elevated above 
the skin. They are spread over the abdomen, sometimes over the chest, more 
rarely over the thighs and arms. These small spots are more evident in pro- 
portion as the skin is fair. Their number cannot be accurately determined, be- 
cause they are not all equally apparent; but to render them a characteristic of 
typhoid fever, they should be to the number at least of fifteen or twenty. 



148 Chomel's Clinical Lectures on Typhoid Fever. 

causes for the most part appreciable, and may occur a number of 
times in the same individual; circumstances which are not true of 
typhoid fever. The invasion of enteritis may be sudden, but never 
unexpected as in typhoid fever. The febrile symptoms are less de- 
veloped, and generally of shorter continuance; the discharges from 
the bowels are more numerous, more painful, and attend the whole 
course of the disease; while in typhoid fever they often occur only at an 
advanced period, or are even entirely absent. The prostration of 
strength when it is present in enteritis is never so decided as in ty- 
phoid fever; the adynamia, stupor, dark coating of the tongue and 
gums, the involuntary evacuations, the ataxic symptoms, delirium, 
subsultus tendinum, are extremely rare in enteritis, as well as the 
eruption of red spots, the sudamina, meteorism, ulcerations of the 
parts upon which the patient lies, &c. 

With respect to colic, the character of the pains, and the absence, 
in the majority of cases, of the general phenomena peculiar to typhoid 
fever, will enable us readily to distinguish the two affections. 

A latent inflammation, when it occurs under the circumstances in 
which typhoid fever usually attacks, and presents one of the forms 
under which it is the most frequently observed, may cause some un- 
certainty in the diagnosis; but an attentive observation of the pheno- 
mena which occur during a few days will, even in the most obscure 
cases, enabled us to decide with certainty. 

The acute phlegmasise occurring in old persons will frequently 
from the commencement, or after a short time, assume an adynamic 
form; the same is true also of the diseases of the urinary organs in 
similar subjects. The age of the patients is here sufficient to enable 
us to decide that they are not cases of typhoid fever, as the latter 
affection occurs only in young persons. 

Among the diseases which may be easily confounded with typhoid 
fever, phlebitis is the most prominent. But it is very rarely that this 
disease is developed spontaneously; most frequently it results from 
wounds, or surgical operations, particularly venesection, and likewise 
subsequent to parturition. These circumstances will suffice to direct 
the physician to a correct diagnosis. From a retention of a part of 
the placenta in the uterus, after delivery, for several weeks, well- 
marked adynamic symptoms often occur, and which may be taken 
for those of typhoid fever. Examination of the uterus and the sani- 
ous discharge per vaginam will here prevent any mistake, and besides it 
is extremely rare to meet with typhoid fever during the puerperal state. 

Latent peritonitis complicated with adynamia in a young subject, 
constitutes one of the cases in which a correct diagnosis is the most 
difficult. Peritonitis, however, is most frequently attended with 



Chomel's Clinical Lectures on Typhoid Fever. 149 

vomiting, constipation, effusion to a greater or less extent in the ab- 
domen, or a sinking in of the abdominal parietes, which appear, as it 
were* glued to the vertebral column; while typhoid fever is accom- 
panied with diarrhoea, even involuntary stools, and a meteorism more 
or less extensive, of the abdomen. 

There are cases of typhoid fever of the ataxic form in which the 
diagnosis is to a certain degree difficult from the analogy of the symp- 
toms with those of the cerebral phlegmasise. This difficulty will exist 
especially when the patient is already in a state of violent delirium, 
or profound coma, with subsultus tendinum or permanent contraction 
of the limbs, and we have no accurate information as to his previous 
symptoms. If the skin does not present the lenticular rosy spots, if 
there is no indication of a haemorrhage having occurred from the nos- 
trils, and if there is no diarrhoea, we cannot decide in such cases po- 
sitively that the disease is typhoid, and we shall be obliged to remain 
in doubt for several days. 

The foregoing remarks of the author upon the diagnosis of typhoid 
fever, are presented, as we have already said, to give our readers some 
idea of the morbid phenomena to which that term has been applied by 
M. Chomel. It will be evidently perceived from these remarks that 
the author considers typhoid fever to be a specific disease, and to re- 
quire to a certain extent a specific mode of treatment; an opinion, 
however, which he is very far from having established by the facts 
which he has adduced. Notwithstanding M. Chomel professes to 
draw his inferences invariably from repeated clinical observations, 
yet from an attentive perusal of the work before us, it will be found 
that his pathological views of typhoid fever are little else than a series 
of hypotheses, the premises upon which they are founded being un- 
supported either by the morbid phenomena presented in the course 
of the disease, or the nature of the lesions discovered after death. 

The author's remarks upon the remote and exciting causes of the dis- 
ease are as little satisfactory as those in relation to its nature. The 
causes of typhus fever, he observes, are enveloped in the greatest 
obscurity. We are well acquainted, it is true, with some of the cir- 
cumstances under the influence of which it is most frequently deve- 
loped; but the exciting cause, that by the action of which it is actual- 
ly produced, has as yet escaped all our investigations. We have al- 
ready referred in a note to the statement of the author in regard to 
the period of life, to which according to his observations the disease 
is almost exclusively confined; namely, that between the eighteenth 
and fiftieth years. He has also found it m.ost liable to affect per- 
sons recently arrived in a large city. It more commonly prevails, 

13* 



150 ChomePs Clinical Lectures on Typhoid Fever. 

likewise, during periods when there exists a scarcity of the neces- 
saries of life, as well as during periods of general distress from what- 
ever this may result. In regard to the question of contagion, the author 
has with great fairness presented the arguments on both sides, but 
appears himself to incline to the affirmative side. Nevertheless he 
admits that if the disease be really contagious, it is so only in a very 
feeble degree, and under circumstances which have as yet not been 
satisfactorily determined. 

We cannot follow M. Chomel in his description of the symptoms 
which mark the several forms of typhoid fever, nor his account of the 
phenomena which indicate the mildness or malignancy of the disease, 
or point to a favourable or unfavourable termination; and we have but 
a few remarks to make upon the author's directions for its treatment. 

In the mildest and most simple cases of typhoid fever, he directs, 
at the very commencement, the detraction of blood from the arm, 
which has the efifect of diminishing the pain of the head and shorten- 
ing its duration, and of preventing the development subsequently of 
more serious symptoms. When the pain of the head is very severe, 
he likewise recommends the application of leeches behind the ears 
with cold applications to the scalp. In addition to the above, the re- 
medies are cooling drinks, mucilaginous injections, daily repeated, 
and emollient cataplasms or fomentations to the abdomen when this 
is painful; when the pain is acut6 leeches also are to be applied. When 
the heat of the skin is considerable the body is to be sponged with 
cold vinegar or water. If there is a tendency to coma or delirium, 
hot applications or sinapisms are to be applied to the extremities. If 
the bowels are not freely opened, mild laxatives are to be administer- 
ed; if diarrhoea be present, this is to be restrained by mucilaginous 
drinks, starch injections, &c. The foregoing, in conjunction with the 
strictest cleanliness, pure air, a proper regulation of temperature, &c. 
constitutes the whole treatment necessary in the milder forms of the 
disease. 

In the inflammatory form of typhoid fever he directs bleeding and 
the ordinary depletory remedies, more or less vigorously employed, 
according to the age and vigour of the patient, and the intensity of 
the symptoms; with this precaution, however, that these remedies 
must not be carried to the same extent as in other inflammatory af- 
fections. 

In the bilious form of typhoid fever a nearly similar treatment is 
demanded; in certain cases both emetics and purgatives will be proper. 
In the mucous variety the same remedies will in general be required 
as in the more simple form; only in place of mucilaginous or acid 
drinks the author prefers those which are slightly bitter or aromatic. 



GhomePs Clinical Lectures on Typhoid Fever. 151 

In the ataxic form, when the symptoms are of an inflammatory type, 
depletory remedies are demanded^ when adynamic, tonics should be 
resorted to. In the purely adynamic form of typhus fever, the proper 
treatment will consist in the judicious administration of tonics, aro- 
matics and stimulants, as wine, camphor, and sometimes ether. 

"It is important, however," he remarks, "not to commence upon a tonic 
treatment during- the period when the reaction, already too intense, might by 
such a treatment be excited to an unfavourable extent. At the same time, it is 
■not less important that we do not delay our tonics until the strength of the pa- 
tient is completely exhausted and cannot ag-ain be roused. It is difficult to in- 
dicate precisely the period of the disease at which all depletory remedies 
should be suspended and tonics be commenced with; it is at the bedside cf the 
patient rather than from books that this point is to be determined. 

** Wine, which in this disease is at once an active remedy and admirable ali- 
ment, is not equally well adapted to every case. If there be present delirium 
or symptoms of cerebral congestion, its use should be suspended, as it will then 
Lave the effect of very certainly increasing these affections." 

When administered it is to be given in spoonful doses, at first one 
or more times per diem, subsequently every few hours or every hour, 
and at a more advanced state still more frequently, mixed with the 
ordinary drinks of the patient. The use of the wine is to be restrict- 
ed as much as possible to the intervals of the exacerbations. 

Ether is said to be useful, more especially when we desire to rouse 
promptly the actions of the system. 

M. Chomel presents some very favourable but cautious observa- 
tions in regard to the treatment of typhoid fever by the chloride of 
soda. In the proportion of one to two grains to an ounce of mucilage 
or weak bitter infusion it was given internally; the patient taking of 
this solution from three to five basins of eighteen ounces each during 
the day. It was also given in injections combined with mucilage in 
a similar proportion, night and morning; the body was washed with 
the pure chloride four times in the twenty-four hours, the cataplasms 
applied to the abdomen were also sprinkled with it, and to each of 
the baths in which the patient was immersed a pint was added, the 
coverings of the bed were sprinkled with it at short intervals, while 
vessels filled v/ith it were placed beneath the bed. In l%olJive patients 
were treated in this manner, all of whom recovered, while f^i fifty-one 
subjects treated without the chloride, sixteen died. From November 
to August, 1832, twenty -three patients with typhoid fever were ad- 
mitted into the Clinic. Fifteen of these, the symptoms of which were 
very severe, were treated by the chloride of soda, and eight without 
it. Five of the latter with symptoms of little severity were cured. 
Of the first, thirteen recovered; one of the fatal cases presented after 
death hepatization of the lungs and tubercles. From November, ISSS^ 



152 Chomel's Clinical Lectures on Typhoid Fever, 

to March, 1834, fifty subjects affected with typhoid fever were admit- 
ted. Thirty-seven of these were treated by the chloride, and thirteen 
without it; in eight of the latter the symptoms were very light, in the 
other three the disease was complicated with pneumonic symptoms. 
Five of the thirteen died. Of the thirty-seven treated by the chloride 
of soda twenty-live recovered. One of those which died was attack- 
ed with cholera, another with pneumonia, another with perforation 
of the lungs and pneumo-thorax during convalescency. A fourth was 
brought in in a dying state, and two others were affected with inflam- 
mation of both lungs. 

" Although the results," remarks M. Chomel, " of the treatment of typhoid 
fever by the chloride of soda, have been very different in different years, the 
remedy is nevertheless that which has been attended with the greatest degree 
of success. Many distinguished physicians have made to us a similar statement 
in regard to it. We continue therefore to test this mode of treatment which, 
combined with other remedies adapted to the symptoms of each case, notwith- 
standing its frequent failure, has presented results more favourable than those 
obtained from any other." 

It is proper to remark that v/e have given above merely an outline 
of the author's directions for the therapeutical management of the fever 
under consideration; we pass by his remarks in regard to individual 
remedies, and to the modifications of treatment demanded for particu- 
lar symptoms and the complications by which the disease is occasion- 
ally attended; not because they are in our opinion injudicious or in- 
correct, but from their possessing no particular novelty; they are the 
same as would be adopted by every enlightened physician. 

The present work of M. Chomel, a brief and perhaps imperfect 
notice of which we have now presented to our readers, is unquestion- 
ably one possessed of no uncommon degree of interest from the accu- 
racy and distinctness with which it delineates the various morbid 
phenomena connected with a highly important class of diseases. And 
yet the degree in which it advances the actual amount of our know- 
ledge in regard to the pathological character of these diseases is but 
small. Notwithstanding the numerous well-observed facts which the 
author presents in relation to typhoid fever, are in themselves im- 
portant, yet his reasoning from these facts is in too many instances 
vague and unsatisfactory. He has erected a certain concurrence and 
succession of morbid phenomena into an entity which, according to 
his views, acts upon the organs, producing in them various lesions; and 
he has described disordered functions, which, were we to admit all his 
conclusions as correct, we must view as being totally unconnected 
with any morbid condition of the organs upon the action of which 
those functions are dependent. D. F. C. 



( 153 ) 



BIBLIOGRAPHICAL NOTICES. 

XIV. An Inquiry into the Claims of Dr. WilUam Harvey to the Discovery of the 
Circulation of the Blood; with a more Equitable Retrospect of that Event. To 
which is added an Introductory Lecture^ delivered on the 3d of Nov ember ^ 1829, 
in Vindication of Hippocrates from Sundry Charges of Ignorance, preferred 
against him by the late Professor Rush. By John Redman Coxe, M. D., Pro- 
fessor of Materia Medica and Pharmacy in the University of Pennsylvania, 
&c. &c. De mortuis nil, nisi-verunn. Philadelphia, 1834. Bvo. pp. 258. 

Upwards of two centuries have now elapsed since the work of Dr. William 
Harvey, De motu Cordis, et Circulatione, in which he describes the action of the 
heart and the circulation of the blood, and claims for himself the honour of be- 
ing the sole discoverer of these important and interesting- physiological facts, was 
first presented to the world. Although, immediately after the appearance of 
tliis work, the claims of the author as the actual discoverer of the circulation 
were strongly contested, and nearly every point in connexion with the question 
became the subject of warm and protracted controversy, yet it appears, that 
all opposition to his claims was either silenced or removed even during the life- 
time of Harvey, while by subsequent writers the entire credit of the discovery 
has been, with scarcely a dissenting voice, fully awarded to him. At the pre- 
sent day, therefore, there are, we suspect, but very few who entertain the 
slightest suspicion as to the correctness of this award. The name of Harvey has 
become so completely identified with the discovery of the circulation, that the 
attempt to prove his claims to be in any degree unfounded will be viewed 
by many as little else than madness. In the work before us. Professor Coxe has, 
nevertheless, endeavoured to show that the evidence in favour of those claims, 
which our profession has so long and so unanimously concurred in, is very far from 
being satisfactory or conclusive. He adduces numerous citations from medical 
writers anterior to or contemporary with Harvey, to prove, that a circulation of 
tlie blood was always accredited, though its exact route and the mode in which 
it was effected were unknown: that nearly every individual fact connected with 
the circulation, as taught by Harvey, and all the various grounds adduced by 
the latter in support of his views, with scarce a solitary exception, are distinctly 
pointed out by others, with whose writings it is not reasonable to suppose that 
he was not perfectly conversant. These premises being established, the claims 
of Harvey are reduced to the having more fully substantiated the facts previously 
known in relation to the circulatory apparatus, and of demonstrating from them 
the true route of the general course of the blood, which had until then remain- 
ed in a state of uncertainty. In the words of Professor Coxe, the honour may 
be ascribed to him of "attaching more firmly the connecting links of an exten- 
sive chain which time had rusted, and possibly, also, of adding slightly to its 
more full perfection." 

Admitting, with our author, that Harvey's views of the circulation of the 
blood were derived originally from the various hints advanced in the writings 



154 Bibliographical Notices. 

of preceding" and contemporary physicians, he was nevertheless unquestiona- 
bly the first who clearly deduced from these hints a correct account of the 
mode in which the blood is transmitted from the heart and again is returned to 
that org"an. By no one, previously to the appearance of Harvey's work on the 
subject, is the true route of the circulation fully and clearly described; -hence. 
In a certain sense, Harvey may with perfect truth be styled the discoverer of 
the circulation. Professor Coxe considers, however, that even to this limited 
extent his claims, strictly speaking-, are unfounded, inasmuch as he has fallen 
into numerous errors and contradictions in relation to the subject; as he has not 
explained fully the mode in which the blood passes from the arteries into the 
radicles of the veins, and hence has not made out the entire route of the cir- 
culation — a point which is not satisfactorily settled even at the present daj' — and 
as he has not explained clearly the powers by which the motion of the blood is 
effected, and was, so far as can be learned from his writings, entirely ignorant 
of the capillary circulation. We pass by those objections derived by Professor 
Coxe from the errors into which Harvey has fallen in regard to, or rather his 
ignorance upon various points of physiology, as these errors do not appear to 
us to have any bearing upon the question immediately before us — they cannot 
in any degree invalidate his claims to the discovery of the circulation of the 
blood, provided that conclusive evidence could be adduced to prove that the 
latter was entirely unknown previously to its announcement by him. 

Professor Coxe has not only impeached Harvey's title as discoverer of the 
circulation of the blood, but he has also adduced evidence to convict him of 
the most unpardonable disingenuousness, in observing* an almost total silence in 
regard to the writings of others, in connexion with the subject of the circula- 
tion, and the anatomy of the heart, veins, and arteries; especially certain writers 
Immediately preceding him, " on the use of the valvular apparatus of the veins; 
the only part nearly that could be regarded as imperfect in the history of the 
circulation," or in referring to them merely to misrepresent or undervalue the 
opinions they advance. 

These circumstances, which are fully made out and established by the pro- 
fessor, in connexion with the intemperate and vulgar abuse in which Harvey in- 
dulges when speaking of his opponents, certainly tend very much to lov/er our 
esteem for the character of that illustrious man, and lead to a strong conviction 
that his right to the discovery which he so imperatively claims rests on a very 
insecure foundation, and hence that he was desirous, in order to add to his own 
fame, of concealing the fact, that in the same field of inquiry upon which he 
had entered any competitor existed, either anterior to or contemporaneously 
with himself. 

Has Professor Coxe in any degree succeeded in diminishing the claims of 
Harvey to the discovery of the circulation? The most prudent course in regard 
to this question would probably be to refer our readers to the evidence detail- 
ed in the work before us, and allow each of them to judge for himself. We 
have, however, no desire whatever to shrink from the clear and candid expres- 
sion of our own opinion in relation to the subject. We reply, then, that many of 
the most important links in the chain of evidence by which the fact of the cir- 
culation is established are proved by Professor Coxe to have been known and 
more or less accurately described by writers preceding the period v/hen Harvey 



Coxe's Inquiry^ ^c, 155 

commenced his investig-ations, and there is almost conchisive evidence that the 
latter was perfectly acquainted with these facts? and that it was by connecting 
together the links thus furnished to him by his predecessors that he was ena- 
bled to demonstrate, as he has done, the course of the blood through the lungs 
and the general aortal and venous systems, in its passage from and to the heart; 
and hence that he is not entitled to the honour claimedby himself and ascribed 
to him by his supporters, of being the first and sole discoverer of the circulation. 

It may be said, that the very same objections to the validity of Harvey's claims 
were urged and completely refuted during his life-time. We believe, however, 
that this is not strictly the case. So far as we have been enabled to investigate 
for ourselves the grounds assumed by those who opposed the views of Harvey 
in regard to the- blood's circulation, immediately after their promulgation, they 
consisted in one or other of the following assumptions. 

1st. That the supposition of a circulation of the blood is founded in error. 

2d. That the circulation of the blood was fully, or at least in great part, taught 
by the ancients; or 

od. That the route of the circulation assumed by Harvey is not the true one. 

Now it appears to us, without touching in any degree the real merits of Har- 
vey's claims, to have been no very difficult task for his advocates to disprove 
such assertions as these, and to silence an opposition which had no more solid 
foundation. Few candid minds could "withstand the demonstrations of the 
circulation as laid down by Harvey," and no one who understood these demon- 
strations, or whose object was to arrive at the truth, could possibly imagine that 
the entire fact of the circulation as taught by him was borrowed from notices 
like the following, the first derived from the writings of Nemesius, a metaphy- 
sical writer of the latter part of the fourth century, and the other from Theo- 
philus, a physiologist of the seventh century; and yet the passages given be- 
low have actually been adduced, in common with many others of similar im- 
port, by some of Harvey's opponents, as convincing proof that the whole of his 
pretended discovery is a mere plagiary from the works of the older writers. 

The words of Nemesius are — 

" The pulsation, which has also been termed the vital power, {^odTM^ J~w£t^/?,} 
proceeds from the heart, especially from its left chamber, termed the pneuma- 
tic, and distributes the vital heat through the arteries to all parts of the body, 
as does the liver the nutritive matter through the blood-vessels." 

According to Theophilus — 

*' From the right chamber of the heart, {AifAciTini) Koixia,) springs the arterial 
vein, {(pKs-^ ci^rii^iaiS)ig,) which conveys the blood of the vena cava to the lungs; 
from ihe left chamber arises the aorta, (a^Tyi^tci Trviu/udLrmn,) which is distributed 
over the whole body, and also the venous artery, {agTue^ici (^Kificeh;,) which con- 
veys the vital heat from the lungs to the blood of the left chamber."* 

From all the facts that we have been able to gather in relation to the subject 
under consideration, it appears evident to us that the claims of Harvey as dis- 
coverer of the circulation were very imperfectly investigated during his life- 
time, while the real character of these claims have been misunderstood from 
that period to the present. The loose manner in which they have heretofore 
been examined, has, indeed, tended more to increase their strength than all the 

• Vide Hecker's Geschichte, 2r. B. pp. 81, 186. 



156 Bibliographical Notices, 

arguments adduced by their supporters. Hence they present still an interesting 
subject for investig-ation, and we know of no one in this country by whom this 
investigation could have been so fully and so fairly pursued as by the author of 
the inquiry before us. Intimately acquainted with the older medical writers, in 
which his library is probably richer than any other private collection amongst 
us? fond of the ancient lore of our profession, and with time and talents perfect- 
ly adequate to pursue a long and laborious chain of inquiry through the dusty 
pages of antiquity, Professor Coxe has engaged in the task he has undertaken 
with means and facilities for its accomplishment which few others could have 
commanded. His work, notwithstanding its arrangement, is faulty, and the chain 
of reasoning of the author is often obscured by unnecessary digressions and re- 
petitions, presents matter of a highly interesting character, and which will 
doubtless be new to the major part of his readers. For ourselves, although we 
had studied with some attention the celebrated work of Harvey, and have 
dipped somewhat deeply into the pages of the antiquated writers of our pro- 
fession, we confess that we have learned from its pages many facts of which we 
were before ignorant, and have acquired a more perfect acquaintance with the 
gradual steps by which a full knowledge of the circulation was attained, than 
we before possessed. 

We fear, however, that in consequence of the author having presented all 
his quotations in the Latin, unaccompanied with a translation, his book will be 
rendered a sealed one to a numerous class of those to whom it is dedicated. 
With Professor Coxe we sincerely regret the almost total neglect of the learn- 
ed languages by the physicians of this country; nevertheless, we conceive that 
he might, with propriety, have withheld some portion of the censure he has in- 
dulged in on this point. He is perfectly aware that to the University of the 
Medical Faculty of which he is a distinguished member, or at least to one of its 
Former professors, is in a great measure to be ascribed the very neglect he re- 
probates. Even now it requires of those whom it admits to the doctorate no 
evidence of their classical attainments, and elevates alike to the same honours 
the illiterate and the learned, provided they can pass with credit their profes- 
sional examination. 

Appended to the Inquiry into the claims of Harvey as discoverer of the cir- 
culation of the blood, is an introductory lecture delivered by the author a few 
years ago to his class, in which he triumphantly vindicates Hippocrates from 
the charge of ignorance prefered against him by the late Professor Rush. For 
this judicious attempt to revive our interest in the writings of the illustrious 
father of medicine; writings which, by the labours of their numerous commen- 
tators, were made to exert for centuries a powerful influence over medical opi- 
nions and practice, Professor Coxe deserves our sincerest thanks. While the 
name of Hippocrates is so frequently referred to, how few physicians are there 
who are at all acquainted with his real merits and the claims which his numer- 
ous works present to our respect and attention! Although we cannot, with cer* 
tain enthusiasts of a former century, extol those writings as presenting the only 
true views in pathology and therapeutics, yet we must admit that they are 
nevertheless, generally speaking, rich in facts, the result of close and extensive 
inquiry, while several of the treatises of Hippocrates might even at the present 
day be read by the medical student, and even the practitioner, with not a little 
profits D. F, C. 



Cyclopedia of Practical Medicine, ^"C, 157 

XV. The Cyclopedia of Practical Medicine and Surgery,- a Digest of Medical 
Literature, Edited by Isaac Hays, M, D., &.c. Parts III., IV., and V. 

These three numbers of the Cyclopedia complete the first volume of the 
work, and include all the subjects under the letter A. so far as Angina Pecto- 
ris. The medical public have now a fair opportunity of judging- of the general 
character of the Cyclopedia, and of the extent to which they may expect the 
promises held out in the prospectus to be redeemed. 

The great object aimed at in a work like the present, is not, as some would 
seem to imagine, to present novel opinions in regard to the various subjects 
embraced in its pages, nor to record the experience of any particular indivi- 
duals or school of medicine; it is one of far greater extent and usefulness. It 
is to present in a condensed form, but sufficiently in detail for all practical pur- 
poses, the actual state of our knowledge upon all those branches into which 
the medical and surgical sciences, properly speaking, are divided. Collecting 
valuable materials from every available source, separating facts from hypotheses, 
comparing the experience of the profession abroad with that of our own phy- 
sicians, and placing to the credit of each the additions and improvements which 
they have respectively contributed — thus presenting a fair exposition of the 
current doctrines of the day in conjunction with those of the older writers, the 
truth of which has been confirmed by a long succession of experience; a work 
of this character constitutes, what the editor announces the Cyclopedia to be 
intended for, a complete library of the medical sciences. In the highest de- 
gree useful to the members of the profession generally, such a work is particu- 
larly so to those who live remote from extensive public libraries and the grand 
centres of medical and scientific information, placing as it does within their 
reach, and in a form which renders a reference to any particular subject per- 
fectly easy, '*a digest of the existing state of knowledge in all the branches of 
the healing art.*' 

How far the present work is deserving of this character, must be kft to the 
decision of the profession at large. So far it has certainly not disappointed 
the most sanguine anticipations of its friends. Taking the five numbers already 
published as a fair specimen of its general plan, and of the talents of the wri- 
ters engaged in it, both in a scientific and literary point of vie\\', we have no 
fear as to the judgment that will be pronounced upon it by the medical public; 
we have an assurance that every American physician will feel a pride in ex- 
tending towards it his support. In the volume just completed, the editor has 
evinced a commendable zeal to present a faithful record of the medical and sui'- 
gical practice of this country. It will be seen by an advertisement which accom- 
panies the fifth number, that from the liberal and honourable manner in which 
some of the most distinguished members of the profession have placed their 
unpublished observations and cases at the disposal of himself and his colleagues, 
the work presents even more of an original and Americaln character than was 
promised; and this we are informed will be found to be the case to a still 
greater extent as the work proceeds. 

It is neither necessary nor expedient for us on the present occasion to enter 
into a detailed examination of the whole of the contents of the three numbers 
before us. It would be impossible, indeed, without extending our remarks be- 
No. XXIX.— November, 1834. 14 



158 Bibliographical Notices. 

3ond the limits of a bibliographical notice, to examine succinctly even the more 
prominent articles embraced in their pages. We may be permitted, however, 
merely to refer to a few. The subject of Alteratives and that of Anemia are 
treated by Dr. S. Jackson in his usual happy manner. On both, the views of 
the author will, if we mistake not, be found to be highly judicious, and in a 
practical point of view all-important. 

The well-known talents of Dr. Bache as a chemist and physician, his com- 
mendable cautiousness and ac€tiracy, are a sufficient guarantee for the excel- 
lence of the articles Albumen, Alcohol, Alkalies, Alum, Ammonia, &c. contri- 
buted by him. The reader will find in them all the most important and useful 
facts in relation to each subject treated of, presented in a concise but clear and 
intelligible style. The same remarks will hold good in reference to the articles 
Allium, Aloes, Almonds, Ammoniac, &.c. from the pen of Dr. Wood. From 
the pen of Dr. Dewees we have the article After-pains, and an admirable arti- 
cle on Amenorrhoea. The excellent judgment of the writer and his long expe- 
rience as an obstetrician and practitioner in the diseases of females, render his 
observations on both of the above subjects extremely valuable. 

In the article Affusion, by Dr. Emerson, is contained a very able exposition 
of the therapeutical effects of water when poured upon a part, or over the 
whole of the surface of the body, and of the precautions to be observed in its 
employment in this manner as a remedial agent. 

Under the head of Air is examined the action of that fluid when admitted 
into the veins. This division of the subject is by Dr. Warren, of Boston. The 
facts in relation to it are clearly stated, and the inferences drawn from those 
facts are of very considerable interest, as explanatory of the cause of the sud- 
den and unexpected death which occasionally occurs in patients during certain 
surgical operations, and as pointing out the means for its prevention. The por- 
tion which refers to the action of air introduced into the arteries and internal 
cavities of the body, bears the signature of the editor. 

The principal surgical articles contained in the present number, with the ex- 
ception of those which relate to the affections of the eye, written exclusively 
by Dr. Hays, are three, namely, Amputation, by Dr. Geddings, of Baltimore; 
Anchylosis, by Dr. Horner? and Aneurism, by Dr. Hodge. All of these are 
very able articles, replete with sound practical princi})les. They confer great 
credit upon the respective writers, while they cannot fail to enhance the inte- 
rest and value of the Cyclopedia. 

In the article Ages, by Dr. Condie, will be found a graphic sketch of the gra- 
dual development and decline of the human organism, and of the different phy- 
siological phenomena peculiar to the several stages through which it passes 
from the period of birth to that of extreme old age.. 

The subject of brainless monsters is treated of under the head of Anence- 
phalus, by Dr. Geddings. This article is of consideyable leng-th, and its details 
will no doubt be considered uninteresting by many readers; they are neverthe- 
less of great importance in reference to the physiological inferences to be de- 
rived from them. Considerable industry and research are displayed by the 
writer in the collection of the numerous facts connected with the subject. 

The article Angina Pectoris, one of great interest, is contributed by Dr. 
Chapman. 



Sanson on the Union of Wounds by the First Intention. 159 

Anasarca by Dr. Condie. Reserving- the consideration of the pathology and 
treatment of serous effusions for the article Dropsy, in this article Dr. C. merely 
presents an account of the symptoms accompanying" the external form of that 
disease, with a brief sketch of its varieties, their causes and treatment. 

We must here close our brief and very imperfect notice of a part of the con- 
tents of these numbers. After a very careful, and we can say with g'reat truth, 
entirely unprejudiced examination of the several articles which they comprise, 
we feel no hesitation in recomraending- the Cyclopedia of Practical Medicine 
and Surgery to the patronage of our medical brethren throughout the United 
States. We are perfectly aware that to render a work of this kind deserving" 
of their support, demands on the part of its conductors talents of no ordinary 
character. We believe, however, that the deservedly high standing of the seve- 
ral contributors, their extensive professional experience, and the evidence 
which they have already given of their capacity faithfully to fulfil the important 
task they have undertaken, will remove all doubts as to the character of the 
succeeding volumes. F. 



XVI. Be la Reunion Immediate des Flaies, de ses Advantages et de ses Inconve- 
nients. Par L. J. Sanson, Chirurgien de I'Hotel-Dieu de Paris. Paris. 1834. 
pp. 115. 

In a recent No. of this journal we noticed the very interesting work of M. 
Serre, upon union of the first intention; a work written to secure the claims of 
M. Delpech, and those of the school of Montpellier, from the neglect of the 
profession in Paris. The remarks made in that article foreclose many of the 
commentaries that we should be inclined to make upon the essay before liS, 
and may serve as an apology for now offering the public a hasty bibliograph, 
where the importance of the subject would otherwise seem to demand a grave 
review. 

M. Sanson is one of the pupils of the school of Dupuytren, and is well known 
as the author of the surgical portion of the beautifully lucid treatise on the 
Elements of Pathology published in conjunction with M. Roche, in 1827. He 
is at present one of the surgeons of I'Hotel-Dieu, and his views may be consi- 
dered as those generally entertained by the leading surgeons of that noble in- 
stitution. In the work under notice we are furnished in the earlier chapters 
with a clear view of the local and general phenomena of immediate union in 
■wounds, the constitutional and local conditions and treatment that favour or op- 
pose its success, and the physiological history of secondary union In wounds 
with and without loss of substance. Then follows an outline of the proper treat- 
ment of wounds in particular regions of the body, with especial reference to the 
propriety or impropriety of attempting primary union in individual cases. The 
second article treats of immediate union as it is practised after surgical opera- 
tions other than amputations, and the third is devoted to the argument on the 
propriety of attempting this mode of cure after the latter class of operations. 

The work has little claim to originality, but is highly interesting, as furnish- 
ing some insight into the causes which have retarded the progress and dimi- 
nished the success of the treatment of wounds by this method in France, and 
particularly in Paris. Perhaps the greatest defect of most French pathologists. 



160 Bibliographical Notices. 

(we say most, for there are some noble exceptions,) is their too g-reat anxiety 
to simplify. From a few well-founded, and it may be, indisputable postulates, 
they deduce apparently logical conclusions, which they attempt to apply inva- 
riably in practice, forgetful of the fact that all physiological questions involve 
data which in the present state of our knowledge are entirely undetermined, 
and hence our conclusions are at best but approximations. They have invaded 
the domains of empiricism with more success than their brethren in any other 
country, and this is much; but it should be borne in mind that until the science 
of hfe becomes at least equally well known with that of mechanics, the prac- 
tice of medicine must and should continue in some degree empirical. When a 
practical procedure produces a result which appears to conflict with our theo- 
retical opinions, we should not be in haste to reject either the fact or the 
theory; it is not even safe to rank the former among the exceptions to the latter 
without considerable caution. To us these remarks seem to apply with con- 
siderable propriety to the treatise of M. Sanson, but of this the reader will judge 
for himself as we advance. 

The author describes with his usual brevity and clearness the appearances 
presented by a wounded surface during the progress of union, waving the ques- 
tion of the precise origin of coagulable lymph and that of the direct inoscula- 
tion of the divided vessels, but dwelling upon the fact that adhesion, like all other 
vital operations, takes place more slowly in the less vascular and more solid 
tissues than in those of an opposite character. Upon this undoubted fact he 
grounds a practical precept which we cannot regard as at all correct. 

** If two points are placed in contact, one of which presents the conditions 
necessary for a prompt development of the phenomena of adhesion, and the 
other is in the opposite conditiou, inflammation can run its course in the former 
before it is developed in the latter, and the reiinion will be diflacult or will not 
take place at all. If the structure of the wound is such that certain parts, simi- 
lar to each other, or nearly so, are m contact, reiuiion will take place particular- 
ly betvi^een these parts; and if the wound is very complex in regard to the 
number and variety of the tissues interested, the partial reunion of which we speak 
can only take place easily between the integuments forming its orifice, leaving 
a gap beneath in which fluids of various kinds are deposited." p. 6. 

It is obvious that practising upon the positions here laid down, the surgeon 
would avoid attempting the reiinion of many wounds, or if he should attempt it 
he would do so with little confidence of success; and in case of failure he would 
be disinclined to seek any other explanation of his want of success than such as 
his theory provided. We have little doubt that this doctrine is one of the chief 
causes of the slowness with which the plan of union by the first intention after 
amputations has been adopted in Paris. We have space only for a very short 
commentary on the position assumed in the paragraph just quoted. No one 
denies that adhesion takes place more slowly in bone than in free cellular tissue, 
but slowness is no proof of difficulty or uncertainty. There is no tissue in which 
union takes place more surely than in the osseous tissue, as the whole history of 
simple fracture clearly shows. Again, no tissue unites more readily with sur- 
rounding tissues however dissimilar, so long as its vitality is preserved by the 
integrity of its periosteum. Does any one dream of abscess of the elbow-joint, 
or the discharge of the fragment, as a necessary consequence of a neglected 
simple fracture of the olecranon? On the contrary, we invariably find it adher- 



Sanson on the Union of Wounds by the First Intention. 161 

ing- to the surrounding- cellular membrane until that membrane is converted 
into ligament. When the extremities of a fractured femur are left unreduced 
and separated by a portion of muscle, does the adhesive process go over in the 
muscle before it is developed in the bone, and thus leave a cavity round the 
naked fragments, eventuating in an abscess? by no means; each extremity unites 
with the muscle which forms part of the bond of union until its structure is 
gradually changed to a greater or less extent. We have here chosen extreme 
cases in order to render the argument as strong as possible; yet we would not 
be understood to deny that adhesion may take place between the integuments 
and fail in the deeper seated parts of an external wound. When such an event 
does occur we regard it as the result of a want of proper apposition, and not of 
the dissimilarity of the tissues placed in contact, for the latter circumstance, 
though it may retard the period o^ firm and perfect reunion^ cannot in our opi- 
nion effect its certainty. Even the want of complete apposition in the deeper 
parts of a wound is not necessarily fatal to union by the first intention. It may 
well be doubted if extensive wounds are ever entirely cleared of coagulated 
blood after the dressings are completed. There is plenty of evidence to show 
that a considerable amount of blood has often been enclosed under flaps, the 
integuments have closed, and the coagula have not prevented the union by the 
first intention. Who has not seen compound fractures converted into simple 
ones, and running their course without accident in cases in which the integu- 
ments have united in twenty-four hours, over a wound distended more or less 
not only with blood, but with medullary matter escaping from the cavity of the 
injured bone? and who has not often seen superficial wounds unite before the 
removal of the first dressing, without a drop of pus being formed, when blood 
in no inconsiderable amount has oozed out between the adhesive strips for an 
hour or more after their application? If either the identity of tissue, or the ab- 
solute perfection of contact were necessary to union by the first intention, or 
as M. Sanson expresses it, for reunion without suppuration, how different would 
be the known result of most lacerations of muscles, and severe, deep-seated con- 
tusions unattended with external wounds! accidents which diff"er in no respect 
from a wound in which the integuments have united while the inner portions 
remain separated by " fluids of various kinds." 

After a few remarks on the general symptoms, commonly very slight, in- 
duced by direct nervous irritation, or by sympathy, in wounds which unite di- 
rectly, M. Sanson proceeds to notice the " circumstances favourable to union 
by the first intention." They are briefly as follows: — 1st. Life and free circulation 
in both surfaces of the wound. The author grants the validity of the evidence in 
favour of the possibility of grafting one part of an animal upon another, and of 
the occasional reiinion of parts completely severed from the body, but very 
properly considers them as bare possibilities. 2d. The recent occurrence of the 
wound and its slight exposure to the air. ^d.. Freedom from contusion. 4th, The ab- 
sence of foreign bodies from the wound. Here the author alludes to the unavoid- 
able difficulty resulting from the presence of ligatures in the wound. He 
seems to favour the idea that the method of arresting haemorrhage by torsion 
may hereafter remove much of this " grave difficulty." The inconveniences 
produced by the ligatures, as generally employed in this country, can seldom 
be considered grave, and we doubt very much whether the presence of parts^ 

X4* 



162 Bibliographical Notices. 

however minute, in which vital power is seriously enfeebled by twisting and 
contusion, is not calculated to insure more mischief in a wound than the pre- 
sence of a few slender filaments of silk. The method by torsion has undoubted- 
ly some valuable applications, but it is hardly likely to become a common sub- 
stitute for that by ligature. The author himself makes some remarks, which in. 
part explain this undue importance attached to the action of ligatures in oppos- 
ing union. He sides with Thompson, in opposition to Hunter, as to the ques- 
tion of the vitalization, or absorption of coagula in wounds that heal without 
suppuration — and follows the former in a practical inference, which we could 
never regard as perfectly legitimate, although some of our eminent surgeons 
have been recently influenced by it in practice. 

*' According to Thompson, if a thin layer of blood interposed between the 
lips of the wound does not prevent their reunion, it is because it is absorbed; 
the operation of adhesion does not commence till after this preliminary opera- 
tion is completed; whence results the important precept, adopted hy the majority 
of practitioners, to tie even the smallest vessels capable of furnishing blood, and 
to wash' carefully the surface of the wound before proceeding to close it." 
p. 17. 

Having spoken of this practice in the bibliograph of the work of M. Serre 
upon the same subject, we will avoid repetition by referring the reader to that 
article — merely remarking that the presence of a great and unnecessary num- 
ber of ligatures, and the exposure and handling necessary to search out a mul- 
titude of unimportant vessels, must prove a very serious obstacle to union by 
the first intention. The torsion of such numerous points would be scarcely less 
injurious, and indeed could hardly produce so little inconvenience as the inter- 
position of a small amount of blood. 5th. Suitable age. The younger the pa- 
tient, caeteris paribus, the more rapidly does union take place, but, as M. San- 
son remarks, extreme youth may interfere with the mechanical treatment ne- 
cessary to procure accurate coaptation in the wound. He gives the opinions of 
various writers on the proper time for operating in hare-lip; but does not at- 
tempt to decide the question positively. 6th. Good general health. Under this 
head we find some very interesting remarks, showing that lues venerea, scro- 
fula, cancer, &c. even when they uffect the constitution generally, do not ne- 
cessarily prevent or retard the progress of union by the first intention. He gives 
a very interesting case to prove that a state of extreme feebleness is not always 
a bar to surgical operations when that feebleness results from the local affec- 
tion demanding the operation. The patient had all the rational symptoms of 
advanced phthisis; hectic fever, colliquative diarrhoea, nocturnal sweats, &c.; 
and appeared in the last stage of attenuation and marasmus. He laboured un- 
der ulcerated white swelling of the left wrist; had been healthful till his twenty- 
ninth year; never had spitting of blood or glandular swellings, and displayed 
no scrofulous cicatrices. His health had failed within a short period. Want of 
work, consequent misery and privations, a prison, distress of mind, an un- 
healthy apartment, bad diet, and rheumatic pains, superinduced the disease of 
the wrist. The limb was amputated; it healed by the first intention; in twenty- 
four hours every bad symptom disappeared, and he perfectly recovered. 

" But when the debility is original; when the patient has been languishing 
all his life under cacochymia; when the affection, for which it becomes neces- 



Sanson on the Union of Wounds by the First Intention, 163 

sary to perform a serious operation, which only promises success in case the 
wound unites by the first intention, or, at least, with but little suppuration, is 
the result, or so to speak, the last stage of this general condition; above all, 
when this debility is caused by, or has determined an organic affection, such as 
the presence of tubercles in the principal viscera, &c., in all these cases it is 
necessary to abstain from operating, for the operation would only hasten the 
death of the subject." p. 20. 

Lastly, M. Sanson mentions, as one of the most important circumstances fa- 
vouring union without suppuration, the perfect contact of all the wounded sur- 
faces. The remarks which we should be inclined to make upon the great im- 
portance here attached to the shghtest deposition of fluid in any part of the 
wound, have been already given to the reader, and need not be repeated. The 
author then proceeds to make some general and very pertinent observations on 
position and the mechanical treatment of wounds. In speaking of adhesive 
strips, he notices their tendency to produce erysipelas, and thus prevent the 
union in certain cases — a fact which we have dwelt upon in several former ar- 
ticles, and which has scarcely received proper attention in this country, where 
a tendency to this disease is frequently prevalent epidemically. He rejects the 
use of adhesive strips in wounds involving muscles, "because they only unite 
the orifice, and leave a hiatus remaining beneath." p. 26. Though this may 
sometimes furnish an argument against them in transverse lacerations of mus- 
cles, as a general rule, it can hardly be defended; the exceptions are vastly 
more numerous than the applications, and in most cases we should as willingly 
entertain the idea of laying open the integuments over a ruptured muscle not 
complicated with an external wound, as that of not closing them, when prac- 
ticable, over a cavity which cannot be entirely obliterated or freed from coa- 
gula in a case complicated with an external wound — provided only, the closure 
could be effected very soon after the accident. We are at a loss to discover 
why the danger of abscess should be considered materially greater in one of 
these cases than in the other. The alternative, which consists in drawing the 
divided muscle together, with the integuments, by means of very deep stitches, 
a practice pursued by some eminent surgeons, may possibly be successful in 
certain cases, though we believe it is very rarely admissible — a proper atten- 
tion to the attitude of the patient, aided by adhesive strips, or superficial suture, 
being sufficient in a vast majority of instances. M. Sanson strongly disapproves 
of this method. 

The three succeeding chapters of the first article treat of the general mea- 
sures necessary to insure union by the first intention, the local, and the general 
phenomena in suppurating wounds. They are all interesting, particularly the 
first. We cannot pause to analyze them at present, but will merely remark, in 
passing, that M. Sanson considers the puogenic membrane to be produced from 
the coagulable lymph in the same manner with the bond of union in wounds 
which do not suppurate. This membrane, after becoming organized, forms the 
granulations, the cicatrix, and supplies the defect produced by loss of sub- 
stance when such loss occurs; it is therefore the sole agent for the reproduc- 
tion of lost parts, and when perfected by time, constitutes the tissu inodulaire 
of Delpech. The author contends against the opinions of Beclard, Larrey, Cru- 
veilhier, Sec. as to the impossibility of vital actions in articular cartilages, and 
states that he has seen these cartilages to swell and become covered with vas- 
cular vegetations after amputation. 



164 Bibliographical Notices, 

The seventh chapter commences with a very brief outline of the origin of the 
doctrine of union by the first intention, its subsequent neglect and revival. 
Then follows an account of the circumstances which at present determine the 
propriety of attempting or avoiding the closure of a wound by this method. 
The only exceptions to be taken to the principles here laid down, are such as 
are consequent upon the opinions which have been already combated, and the 
same remark applies to the general practical directions for dressing and treat- 
ing accidents of this nature. The chief objection to these directions is that 
they would induce too much interference on the part of the surgeon, the waste 
of far too much time in manipulating before closing the wound, and too little 
trust in the powers of nature. In proof of this we will translate three of the 
directions, which by their strong language appear to explain in some degree 
the more frequent failure of attempts at union in Paris than in other places, a 
fact that is sufficiently proved in the work of M. Serre, already quoted. These 
directions are — 

'* To absterge with care all the surface of the solution of continuity with a 
fine and soft sponge, charged with warm water, in order to remove scrupulously 
even the last clot of blood. If vessels sufficiently considerable to be visible are 
divided, to tie them, even to the most minute. To take care in every case, before 
proceeding to relinion, that the flowing of blood should be completely arrested.'^ 
p. 59. 

The remainder of this chapter is given to the consideration, in a cursory 
manner, to wounds of particular parts of the body. Under the head of wounds 
of the cranium the author recommends the suture with perhaps too little regard 
in cases where the flap forms a dependant cul-de-sac; ligatures on the hairy 
scalp produce more irritation than in most other parts, and are very prone to 
cause inflammation. Moreover wounds of the surface of the cranium are so 
completely manageable by means of adroit bandaging, that suture is very seldom 
necessary. He lays considerable stress upon counter-irritation of the extremities 
in threatened inflammation of the scalp. In commenting upon Baron Larrey's 
occasional success in sabre cuts involving the scalp, the cranial bones and a part 
of the cerebral substance, he lays it dov/n as a law admitting no exception, that 
in such cases no attempt should be made to unite the wound for fear of com- 
pression of the brain by the effused blood, or the subsequent suppuration. 
Though this law must be regarded as generally correct, there are cases in which 
the chance of success is even less considerable than in incised wounds, and yet 
we think the attempt at union should be made as the least of evils. 

In speaking of transverse wounds of the neck he strongly recommends the 
suture, and when alluding to the suffocation resulting from retraction of the 
trachea, or from bleeding into the tube, he impresses the necessity of waiting 
for the entire arrest of hsemorrhage before closing the wound. Without sharing 
in the great dread, expressed by M. Sanson, lest the direct admission of air 
into the tube should occasion fatal suppuration, we fully admit that the strictest 
attention to the three practical directions which we just now censured in their 
general application, is indispensable in cases of this character, and consequently 
we seldom anticipate complete union of the whole wound by the first intention 
when the trachea or larynx has been extremely injured. The author recom- 
mends suture through the cartilages in case of threatened suffocation after com- 
plete division or repeated incisions of the larynx or trachea, noticing M. 



Sanson on the Union of Wounds by the First Intention. 165 

Castan*s successful case in which he punctured the ossified cartilages with a 
trochar, in order to introduce the needle. Cases may occur, positively demand- 
ing such measures, but as the present learned professor of surgery, Dr. Gibson, 
justly remarks, by such means *'a troublesome cough and an incessant irrita- 
tion will be kept up." (Institutes and Practice of Surgery, v. I. p. 160.) To 
avoid this difficulty, the lining membrane should be avoided if possible, when 
suture is absolutely demanded. As a general rule we should say that extensive 
wounds of the larynx and trachea do not admit of entire closure within the time 
necessary to cause immediate union, because sometimes the flow of blood cannot 
be perfectly, securely, and permanently arrested until several hours have elapsed, 
and if the whole wound be closed by suture there is great probability that the 
stitches will be torn out by coughing, or that they must be cut by the surgeon 
to prevent imminent suffocation. Adhesive strips for the corners, and position 
for the centre of the wound, furnish the most rational means of treatment, and 
if the latter portion should suppurate, the danger of an extension of the inflam- 
mation to the tube cannot be so great as M. Sanson seems to infer. On wounds 
penetrating the cavities of the thorax there is nothing of very particular interest 
except a dangerous case of wounded lung, by M. Taxil, in which the blood was 
evacuated by enlarging the orifice, and with success, proving the occasional ex- 
ceptions to the general law, that such wounds should be immediately closed. 
One word on the subject of wounds of the extremities. 

" A question, more important and long debated, is whether or not union 
should be attempted in wounds complicated with fracture. The numerous fail- 
ures made in endeavouring to preserve members, had caused many distinguish- 
ed practitioners to think that it was better to amputate, than to attempt the 
preservation of the members. Now, however, it is conceded that there exists cer- 
tain exceptions to the rule, &c." p. 81. 

The exceptions noted are cases in which the wound and fracture, separately 
considered, are both simple and free from contusion, those in which the wound 
is produced by the ends of the bone penetrating from, within outwards, and in 
which the accident may be easily reduced to the condition of a simple fracture. 

** But the question rests entire for wounds accompanied by fracture by direct 
causes, and complicated with splinters and considerable contusion; or to speak 
more correctly, it is decided: these cases demand amputation. Such has been, 
and such is still the opinion of the most distinguished surgeons of the capital^" 
&c. p. 82. 

We believe that some American surgeons of the highest eminence are some- 
what blameable for amputating too seldom; but it is hardly necessary to com- 
ment upon the above passages, further than to ask whether their exceptionable 
character is due to errors in practice, or to looseness of language and undue 
decision of manner. We cannot believe that any surgeon of the Hotel-Dieu, 
much less the most distinguished surgeons of the capital, would consider, in 
civil practice, the existence of compound fractures when complicated with 
splinters and considerable contusion, as cases generally demanding immediate 
amputation. Cases coming within this description recover every day, and often 
with little difiiculty. 

In quitting this section, we will merely venture the general remark, that M. 
Sanson seems to carry, even further than most French authorities, the practice 



166 Bibliographical Notices. 

of moistening the dressings with fluids, a practice which invariably lessens the 
security of adhesive strips when they are employed, and which often disturbs 
the process of reunion in the lips of a wound, by softening the scab or dried se- 
cretion which usually protects them, and in many instances leads to superficial 
suppuration, even when it does not produce more serious inconveniences. We 
are averse to any attempt at combating evils before they have actually occurred, 
and if cold and moisture are required in the treatment of wounds, it is only 
during the commencing stage of acute inflammation? if employed before the 
proper time, they not only embarrass the process, but may produce the very 
evil they are intended to prevent. This may appear a minute observation, but 
success in surgery, as in all other things, depends much upon details apparently 
trivial in their nature. 

Passing over the second article, which is for the most part a mere enumera- 
tion of the cases in which union by the first intention ought or ought not to be 
attempted iu cases of operations not involving amputations, an enumeration to 
which no exception can be taken, we come to the third article. On the Advan- 
tages and Inconveniences of Immediate Union in Wounds produced hy Amputation, 
This is the great point of controversy in which the north of Europe, England, 
the United States, and the school of Montpellier may be regarded as taking the 
aflirm.atiye side, Paris the negative, and Italy a neutral ground. M. Sanson ap- 
pears at first disposed to argue in favour of the affirmative, but his final con- 
clusion will be mentioned presently. 

It is impossible, within our present limits, to treat this subject in detail, fop 
we should be obliged to discuss much of the matter, sentence by sentence, at 
considerable length. Leaving the first part of the work, then, to contend with 
the second, and where this fails, calling in the aid of M. Serre, of Montpellier, 
who has been somewhat neglected by our author, we must content ourselves 
with a few observations on two or three points of some importance, we will de- 
fer the argument till a more suitable occasion offers. 

** The English are so persuaded of the necessity of tying even the smallest 
vessels capable of furnishing blood, in order to insure reunion, that in order 
to render them apparent, they sometimes endeavour, according to the report of 
M. Avery, to excite the circulation and local heat by causing the patient to take 
a little warm wine, covering the stump with a little flannel wet with warm 
water, frequently renewed." p. 100. 

Now, though the second part of this process may have been used, although we 
never recollect to have heard it mentioned, the first part, i. e. the use of wine, is 
frequently resorted to, but with a design very diff'erent from that supposed by the 
author. It is very common for a patient to be found almost in a fainting condition 
at the close of an amputation, and under such circumstances we have even seen 
the femoral artery refuse to bleed. The wine is given to quicken the circula- 
tion, in order that the considerable vessels may be detected without unnecessary de- 
lay and exposure, for fear the reiinion should be endangered. It would perhaps 
surprise M. Sanson to hear that we have seen cold water employed in some rare 
cases to check the oozing of blood, in order that the closure of the wound 
might not be improperly delayed in the search for very minute vessels; and 
that such cases have been highly successful. Doubtless there are some sur- 
geons, both in England and America, who would approve of keeping the wound 



Sanson on the Union of Wounds by the First Intention. 167 

open for an hour or more, as advised by Dupuytren, in order to discover and 
tie the smallest vessels, but such is any thing" other than a national custom in 
either country. It is very rarely that half that time is allovs^ed, nor is it cus- 
tomary with most to employ numerous ligatures, except in cases of unusual dis- 
position to haemorrhage. The doctrines of Thompson on this subject appear 
to have produced a false impression in Paris. 

Our author attributes the greater part of the unfortunate terminations after 
amputation to phlebitis, which he considers as more probable in cases of at- 
tempted union, than where the opposite plan of treatment is pursued. This 
accident is very rare in America, and though it may be well supposed that the 
great hospitals of Paris are more subject to the endemic erysipelatous tendency 
which renders it more frequent, than are the smaller institutions in this coun- 
try, we cannot avoid the impression that other causes must cooperate in pro- 
ducing the vast difference in results. We possess at present no means of tabu- 
lar comparison, but our readers will be astonished to have the following details 
of the results of amputation abroad. 

Observers. No. of Observations, Proportion of Deaths, 

Dupuytren* - - — - - - - - linS 

Roux* ... — ..-. = 1 in 3 

Larrey* - - - — - - - - - 1 in 6 

Dubois - - - 28 - - - - - 1 in 9 

Lucasf - - - 70 - - - - - 1 in 14 

Percyf - - - 92 1 in 15 

Freeref - - . 27 1 in 27 

Maunoirf - - - 30 = - - - - 1 in 30 

Kennedy! - - - 11 - - - - - None. 

Alansonf ---36 None. 

Those marked with an * may be regarded as opponents to the plan of re- 
union, though the two first are said not to reject it in all cases. (See Serre, Op. 
Git.) M. Dubois is associated with M. Richerand, and is considered an advo- 
cate. (See the Observations of Serre on this point also.) The rest marked 
with a -j- are decided advocates of the doctrine. M. Sanson labours ingeniously 
to weaken the obvious force of the argument founded on these observations; 
with what success the reader may judge after consulting the work. He finally 
declares in favour of keeping the integuments separate by a roll of lint, allow- 
ing the deeper-seated parts to unite. If he had confined himself to a partial se- 
paration at one or both ends of the wound, to secure free exit to any pus acci- 
dentally formed, he would not have been without most able defenders on this 
side of the atlantic. 

In conclusion, we would remark, that the work under examination, together 
with that so frequently referred to in the course of our remarks, give a very 
fair view of the state of medical opinion on this most important subject among 
the leaders of the two great schools of France, and would therefore prove a 
valuable addition to the library of American physicians. R. C. 



168 Bibliographical Notices. 



XVn. Jnnsvnide7ice de la Mcdecme, de la Chirurgle, et de la Pharmacies en 
France,- comprenant la Mddedne Legale, la Police Medicale, la Responsahilite 
des Medecins, Chirurgiens^ Pharmaciens, &c.; PExposS et la Discussion des 
Lois, Ordonnances, Reglemens et Instructions concernant Part de gu^rir,- appuye 
des Jugemens des Cours et des Trihunaux. Par Adolphe Trebuchet, Avocat, 
Chef du Bureau de la Police Medicale et des etablissemens insalubres a la 
Prefecture de Police. Paris, 1834. pp. 756. 8vo. 

Collection des Rapports Generaux sur les Travaux du Conseil de Saluhrite de la 
ViUe de Paris, et da D^partement de la Seine, &c. Par V. de Moleost. Tome 
1. Paris. 1830. pp. 404. 8vo. 

These two works, although principally devoted to an exposition of the laws 
regulating- the medical and pharmaceutical professions in France, contain much 
that is instructive and interesting-. The provisions of the French law, with respect 
to the safety and well-being of the inhabitants of that country, are admirable, 
and although many of them would appear arbitrary, and could never be en- 
forced in the United States, still there are a vast number which would conduce 
much to our happiness and comfort if put in force here. 

The system of the French Code Sanitaire is excellent, and the organization 
of the Conseil de Saluhrite of Paris, shows that the government of that country 
is fully impressed with the necessity that the members composing it should be 
men of intelligence, and fully competent to decide on the cases that constantly 
come under their supervision. A perusal of the reports of this body, as given 
by M. de Moleon, will show that the business of that board of health is very 
differently conducted from those of the United States, and present the curious 
anomaly that under a regal government there is more caution in infringing on the 
rights of its subjects, with regard to the removal, &c. of what are termed nui- 
sances, than takes place in this country, where, from the mode in which our boards 
of health are constituted, orders are issued for draining ponds and the suspension 
of certain trades, on the mere dictum of a body of men, who, however estima- 
ble they may be in the walks of private life, are, from want of the proper know- 
ledge, but ill calculated to decide on such subjects. 

It would not comport with the character of the Journal, to enter into this sub- 
ject at length, but we will merely add that we trust that if a revision of our 
health laws should take place, that advantage will be taken of the labours and 
experience of others, and that we may at least be relieved from the operation 
of a code of laws which are calculated rather to oppress our mercantile com- 
munity, than to guard us against the "introduction of malignant and pestilen- 
tial diseases." 

The work of M. Trebuchet contains, in addition to the laws regulating the 
medical profession, several chapters on medical jurisprudence properly speak- 
ing, which are of great interest, as presenting many important cases and the re- 
ports mado on them, elucidating several obscure or disputed points, especially 
the diagiiostics between wounds, &.c. Inflicted by others, or with a suicidal 
intent. We have, however, so often drawn the attention of our readers to these 
and other subjects connected with legal medicine, that we shall pass them over. 



Trebuchet on Medical Jicrisprudence, <^c. 169 

but strongly recommend to those who feel an Interest in this neglected branch 
of medical learning a perusal of this part of M. Trebuchet's treatise. 

We cannot, at the same time, avoid noticing the second chapter on medical 
responsibility, a subject which we believe has never been touched on in this 
country by any medical man, with the exception of a short chapter in the Ame- 
rican edition of Ryan, although we have numerous instances of actions for mal- 
practice. Many of M. Trebuchet's opinions are, we think, controvertible; but, 
on the whole, we have been highly pleased and instructed by his exposition, 
and will endeavour to lay a short abstract of it before our readers. 

He begins by asking, '* if physicians are responsible for errors committed 
in the exercise of their profession," and justly observes, that although, accord- 
ing to the strict letter of the law, there can be no doubt that they are, yet that 
these very laws must necessarily prove nugatory in a majority of cases, from 
the difficulty of any court coming to a proper decision on the subject. In fact, 
as is observed by Dr. Beaude, in animadverting on the award in tlie celebrated 
trial of Dr. Helie for amputating the arms of a foetus in utero, which was after- 
wards born alive and survived the mutilation — 

*' A physician who has been regularly educated and received his diploma to 
that effect, presents to society the best guarantee possible, and having thus 
fulfilled all the obhgations demanded of him, ouglit to be answerable to his con- 
science alone, in the treatment of his patients? ifnot, he is at once trammelled, 
and would not dare to try what perhaps would afford the only chance of escape 
to the patient, because if it failed, or was attended with unfortunate results, he 
at once became responsible for these consequences. The physician who acts 
conscientiously, and does what he deems the best for patients who commit them- 
selves to his care, ought to have no judge but his God; any other doctrine is 
false, and could have but one result, that the morality of actions would be judged 
of by their fruits, and not by their intrinsic merits or demerits." 

We fully agree in the view Dr. Beaude has taken, but at the same time are 
also convinced that certain laws rendering medical men responsible for gross 
ignorance and inattention are required, and more especially in this country, 
where the most arrant and unblushing quack is considered on a par, and even 
inspires more confidence than the physician who has devoted his life to the study 
of his profession. 

There is another point connected with this subject that is of no slight import- 
ance, namely, what is to be considered the standard by which a medical man 
is to be judged, for although the law has equal bearings on all, it is evident, 
from judicial decisions, that much latitude is given to it when brought to be^r 
on particular cases; or, in other words, it has been decided that what would 
be unjustifiable mal-practice in one member of the profession, would not be so 
in another. That such is the fact, however strange it may appear, cannot be 
doubted or denied. Thus, Judge Weston, in the case of Lowell vs. Faxon and 
Hawks — 

*♦ That whoever undertakes to practice physic or surgery, holds out to the 
public that he possesses a competent degree of medical skill, according to the 
general state of the medical science in the section of the country in which he 
lives. The highest degree of skill is not to be expected in small towns, where 
there is little competition and fewer motives for exertion, from the compara- 

No. XXlX.—November, 1 834. 15 



170 Bibliographical Notices, 

tive want of patronage, and the limited opportunities for professional improve- 
ment." 

There can be no doubt as to the correctness of the view taken by Judge 
Weston, under our existing laws, and yet this very opinion is calculated to lead 
to strange results; it in fact establishes a different standard of medical skill for 
each section of country, and even for each village. Who is to decide in such 
cases? Suppose, for instance, a physician of the highest skill and acquirements 
settles and practises in a certain section of country, are the professional talents 
and abilities of all his neighbouring brethren to be measured by his? If so, 
w^hat was innocent and legal practice before his arrival, becomes criminal after 
his appearance. 

In fact, viewed in every light, the subject is environed with difficulties. It 
may be said that all this might be avoided by consultations in all difficult cases, 
or where important operations were to be performed; but this is not always 
feasible, and even granted that it were, if an unfortunate result occurred the 
number of supposed criminals would only be increased. 

We might go at greater length into this important subject, but must content 
ourselves at present with advising such of our readers as have an opportunity 
to attentively peruse this portion of the work in question. R. E. G. 



XVIII. ArzeimittellehreundReceptirkundezum Behufe der Vorlesungen^ entworferi 
von Emais^uel Stephajt Schroff, der Heilkunde Doktor und Professor der 
Theoretischen und Praktischen Medicin fUr Wundarzte an der k. k. Medici- 
nisch-Chirurgischen Josephs-Akademie, und Karl Damiax Schroff, der 
Heilkunde Doktor und Professor der Theoretischen Medicin fiir Wundarzte 
an der k. k. Universitat zu Olmlitz. pp. 428. 12mo. Wien, 1833. 

Materia Medlca and Pharmacy ^ for the Use of the Followers of the Lectures ofF^. 
S. ScHBOFF and Karl D. Schroff, &c. 

This manual, as the title imports, is intended as an accompaniment to the 
lectures of the Messrs. Schroff — the former of whom is professor of theoretical 
and practical medicine for surgeons in the Imperial Medico-Chirurgical Joseph's 
Academy at Vienna, and the latter professor of theoretical medicine for sur- 
geons in the Imperial University at Olmlitz — and it is probably well adapted for 
the purpose, although it would be but little calculated, we, presume, for any 
other meridian than that of Germany. In proof of this we may cite their re- 
marks on the classification of medicinal agents as well as the classification 
itself. 

♦'As all the functions of the body may be divided into two classes, namely, 
into those of organic or plastic (formative) life; and those of animal (sensible 
and irritable) life, so all remedial agents may be ranged under two divisions — 
one of which comprises such as Siffect plastic life, whilst the other includes such 
as more intimately concern animal life. It must not, however, be presumed 
that the agents of one class affect one kind of life only; we are satisfied, that 
each remedial agent impresses the whole life, (^des gesammie leben;J we mere- 
ly maintain, that the agents of the first class mainly modify formative life, and 
those of the second class mainly the higher animal life. Now, plastic life may 
vary from the healthy condition, both as regards quantity and quality; but the 



Schroff's Materia Medica and Pharmacy. 



171 



qualitative aberrations of formative life are too little known for us to attempt a 
corresponding- arrangement of remedial ag-ents. We can, however, separate 
those that correspond to aberrations in quantity, as reg-ards plastic life, into two 
orders; the first of which comprises those bodies that moderate formative life; 
wherein we include — A, evacuantSy and B, relaxants; whilst the second em- 
braces such as elevate enfeebled formative life; wherein we reckon — x\, plastic, 
and B, ionic agents. 

*' The agents of the two classes we divide into two orders — excitants and se- 
datives. Each order, again, is subdivided into two genera; namely, into A, eX' 
citants of sensible life, which are usually termed diffusible excitants; and B, eX' 
citants of irritable life, which are known under the name of permanent excitants. 
The sedatives, again, fall into two genera; namely, A, sedatives of sensible life, 
or narcotics, and B, sedatives of irritable life, or antiplogistics." S. 43. 

In accordance with these views, the Messrs. Schroff offer the following table 
of classification. 



AGENTS. 



Class I. 
Affecting formative life. 

Order \ . 
Moderating plastic life. 
Genus 1. Evacuants. 

Genus 2. Relaxants. 

Order 2. 
Elevating plastic life. 
Genus 1. Plastics. 

Genus 2. Tonics. 



Class II. 

Aff*ecting animal life. 

Order 1. 

Excitants. 

Genus 1. Excitants of sensible life — 

Diffusible excitants. 

Genus 2. Excitants of irritable life — 

Permanent excitants. 

Order 2. 

Sedatives. 

Genus 1. Sedatives of sensible life — 

Narcotics. 
Genus 2. Sedatives of irritable life — 
Antiphlogistics. 



The doses of medicinal agents, as the authors properly remark, must vary ac- 
cording to age, sex, temperament, constitution, habit, mode of life, nature and 
stage of the disease, &c. but they present the following table as in approxima- 
tion to the doses required at different ages. It does not differ essentially from 
that of Gaubius. 



"If we administer to a man, between 25 and 60 years of age, 

a drachm, as a full dose, 

We must give to a youth, between 14 and 25 years, of the same 

agent, 2-3ds; therefore two scruples or - - 
And to a boy, between 7 and 14 years, the half of the full dose; 

therefore half a drachm, or 

To a child, from 4 to 7 years, a third of the full dose; therefore 

a scruple, or 

To a child 4 years old - - ^th . - . - 

Do. 3 Do. - - l-6th . . . . 

Do. 2 Do. - - ^th . . . . 

Do. 1 Do. - - l-12th . . . - 

Do. 6 months old - - l-24th . . . - 

I>o. 3 Do. - - l-48th - 



60 grains. 



- 40 

30 

20 
15 
10 

n 

5 

2* 



li.»S. 36. 
E. D. 



172 Bibliographical Notices, 



XIX. 1831 — Jahres-JBericht ueher das Clinische Chirurgisch-augenarztliche In- 
stitut der Universitat zu Berlin, ahgestatet vora Director der genannten An- 
stall Dr. Carl Ferdinand von Graefb, &c. Funfzehnte Folge, 4to. pp. 34. 
Berlin, 1832. 

The Fifteenth Annual Report, for the year 1831, of the Clinico-Chirurglcal and 
Ophthalmic Institute of the University of Berlin; Drawn up by Dr. C. F. 
VON Graefe. 

The periodical reports of the different hospitals of Germany are in general 
prepared with a great deal of care, and present always highly interesting, often 
very valuable information, both of a statistical and practical character. It is 
much to be regretted that the medical gentlemen connected with the institu- 
tions for the reception of diseased persons in this country, are not more gene- 
rally in the habit of presenting in a somewhat similar form, the statistics of those 
institutions, together with the general facts connected with the particular class 
of patients received into their wards, and with the results of the medical and 
surgical treatment to which they are subjected. In this'manner, with a very 
slight addition to their ordinary duties, they would be able to contribute no in- 
considerable amount of valuable practical information, which physicians less 
favourably situated are precluded from acquiring by their own experience. 

We have before us the very able Annual Report of the Clinico-Chirurgical 
and Ophthalmic Institute attached to the University of Berlin, for 1831, drawn 
up by Dr. C. F. Von Graefe. This report, in addition to a copious table, ac- 
companied with numerous remarks, of the different accidents and diseases 
treated in the institution, exhibiting their character and results, contains a list 
of the physicians and students who attended the clinic during the year, and a 
series of observations on various topics connected with the cases which fell 
under the observation of the author as director of the institution. The several 
sections into which these observations are divided, are as follows: — 

1. A new method of arresting traumatic haemorrhage. In this are presented 
some interesting results of Dr. Graefe's successful experiments in arresting the 
discharge of blood from wounded and divided arteries, by a fluid, the compo- 
sition of which is unknown, and which was first employed by an Italian physi- 
cian of the name of Binelli, in the year 1797. 2. A case of extensive aneu- 
rismal bronchocele occurring in a young soldier, and incapacitating him, from 
its bulk, and the impediment it occasioned to the freedom of respiration from 
performing his military duties, which was completely removed by tying both of 
the superior thyroidal arteries. 3. A notice of the different modes of operating 
for cataract pursued in the Institute, and their general results. 4. Remarks on 
exarticulation by the linear and oval incision. 5. Remarks on Foot's operation 
for phymosis, which is preferred by the author. 6. A case of ramifying aneu- 
rism of the temporal artery, in a child often years of age, cured by an operation. 
7. Case of hgature of the femoral artery. 8. Extirpation of the lower jaw. 9. 
Communications from Dr. Sat Desgalliere. 10. Case of paralysis of the arm 
cured by frictions with setherial spirits of ammonia and internally the Arnica 
blossoms. 11. Treatment of a general eruptive affection; and 12. On the sul- 
phate of quinia as a preventive of cholera. 



Velpeau on Trepanning in Injuries of the Head. 173 

The whole number of patients treated in the Institute during the year 1821, 
was 1649, of which 422 laboured under diseases of the eye. Of these, 1300 
were cured, and 16 died; 243 were removed to other institutions, and 90 re- 
mained under treatment at the close of the year. The number of operations 
performed was 416; of these 5& were upon the eye. The number of individuals 
who attended the Institute during the year was 287, including 136 practitioners. 

D. F. C. 



XX. De V Operation du Trypan dans les Plaies de Tete. Par A. A. M. L. Vel- 
peau, Chirurgien de I'Hopital de la Pitie. Paris, 1833. pp. 274. Octavo. 

We have here another chirurgical treatise, upon a subject of great interest, 
from the prolific pen of M. Velpeau. There are few questions in surgery which 
have elicted more research or greater difference of opinion than that of the 
lime and circumstances demanding the application of the trephine in injuries of 
the bead; and perhaps no one has been loaded with more irrelevant matter in 
evidence, and more palpable non-sequiters in reasoning. In the work before 
us, there is an attempt to define the former and expose the latter, and although 
it must be confessed that the subject is handled with somewhat of the zeal and 
consequent prejudice of a partizan, we rise from its careful perusal with the 
impression that it is calculated to do much good, and no where more especially 
than in this country. It would be vain to attempt a detailed analysis of a vo- 
lume nearly one-half of which consists of a rapid enumeration of facts and opi- 
nions arranged under a great variety of heads, and the great part of the remain- 
der, of a concentrated critique upon the tenets of individuals and schools of 
high authority. We shall therefore confine ourselves to a very general notice 
of the arrangement of the work, with a passing commentary upon a few points 
of peculiar importance. After a very short historical coup-d'oeil, the author 
proceeds, in the second or "dogmatical part,'' to notice, seriatim, all the va- 
rieties of traumatic injuries to which the head may be subjected, pointing out 
where he considers the trephine to be indicated or contraindicated, illustrating 
his positions by many cases and numerous references to authorities. 

Contusions without fracture of the cranium only demand the operation primarily 
when the pericranium and dura mater are both detached, or likely to become so, 
rendering necrosis of the bone almost inevitable. In fractures of the external table 
only, he recommends the removal of all detached fragments as the more ad- 
viseable course. Even when the diploe is crushed by contusing forces, he does 
not inculcate the use of the trephine, unless urgent symptoms supervene, agree- 
ing in this respect with Sir A. Cooper. In fractures of the internal table only, 
the diagnosis is very obscure, and M. Velpeau remarks that they only demand 
the early interference of the surgeon, when a blow, not followed by visible frac- 
ture, produces the symptoms of a foreign body in the cranium, in which cases 
the trephine should be employed without hesitation, under the expectation of 
discovering spicula perhaps penetrating the dura mater. 

In fissure attended with internal extravasation, the plan strongly recommend- 
ed by some surgeons, that of widening the crack by a wedge, is justly con- 
demned, and if the opening is insufficient to give ready egress to the fluids the 
trephine is recommended at once, notwithstanding that in such accidents the 

15* 



174 Bibliographical Notices. 

chances of success are very small, because these crevices are a proof of very ex- 
tensive fracture, often attended with undiscoverable mischief. In multiform 
fractures unattended with displacement, the trephine is only recommended in 
certain cases for the removal of consecutive accidents, but under the head of 
fractures with depression there are some very important remarks. Extensive 
and slight depressions may recover without inconvenience, but deep depressions 
are vastly more dangerous. When fixed or resistent, they do sometimes recover 
without accident^ but the author thinks that when one patient might be saved 
ten would be lost. He grants, however, that in fixed depressions we may wait 
for decided symptoms before attempting to operate. 

"Depression with mobility is infinitely more to be dreaded! An extravasa- 
tion of blood, primitive or consecutive, is frequently the consequence. Even 
when there is no external wound, recovery is very rare. If the fracture is ex- 
posed, necrosis of the moveable fragments and deep-seated suppuration are 
almost inevitable. In all cases such depression is a permanent cause of menin- 
gitis, and pains and nervous accidents of all sorts. The operation of trepanning 
is the only efficacious remedy, and is imperiously indicated; unless, at least, it 
is adviseable to renounce all surgery in wounds of the head." p. 39. 

M. Velpeau considers the trepan almost useless in cases of fracture with 
overlapping of the fragments, but even this rule will not hold in all instances; 
witness the very interesting cases mentioned by Mr. Bransby Cooper, and no- 
ticed in the review of his Essays in this number. 

Under the head of gun-shot fractures and foreign bodies in the cranium, re- 
ference is made to show most clearly, that local contusions and wounds of the 
brain with or without loss of substance and subsequent suppuration of the cere- 
bral matter, are not by any means invariably fatal, when the character of the in- 
jury admits of the free discharge of the fluids and flocculi; while on the contrary, 
every one knows that suppuration to any extent within the hemispheres is in- 
variably fatal, when there exists no sufficient outlet. These facts are the founda- 
tion of the author's opinions on the use of the trephine in cases of the lodge- 
ment of foreign bodies of a fluid nature within the encephalon. He lays it down 
as a general rule that foreign bodies of every description should always be re- 
moved if their presence and location can be detected, nor does he hesitate to 
apply the trephine, to divide the dura mater, or to puncture the brain itself 
when necessary, to accomplish this all-important end. In some rare cases 
leaden bullets have remained in the cavity of the cranium for years without pro- 
ducing death, and it is a curious and important fact, recognised by M. Velpeau^ 
that lead produces less injury to vital tissues than perhaps any other strictly 
foreign substance. Yet these cases in no degree invalidate the law, for thej^ 
may be regarded as almost miraculous. He regards effused blood as a foreign 
substance, and insists on its evacuation under most circumstances, but to this 
there are exceptions. Blood between the dura mater and the bone is always 
collected within well-defined limits, and is rarely found in very great amount. 
From the nature of the surrounding tissues it is absorbed with great difficulty, 
and if extravasated in sufficient quantity to produce the symptoms of compres- 
sion, these can only be relieved by its evacuation. In this situation it is exceed- 
ingly prone to degenerate, and almost invariably gives rise to suppuration in 
consequence of the changes it undergoes. Again, its presence in any quantity 
insures a necrosis of the whole thickness of the bone, which is in itself a suffi- 



Velpeau on Trepanning in Injuries of the Head. 175 

cient reason for the operation, and the operation has a greater chance of success 
if performed before the symptoms of irritation produced by the chang-e in the 
character of the effusion, or by the morbid condition of the tissues involved have 
had time to supervene. If the quantity of blood extravasated is too small to 
prove injurious, its presence can scarcely be detected. It follows, then, that in 
effusions of blood above the dura mater, the trephine should be employed with- 
out hesitation whenever the diagnosis can be made out. The same remark 
holds good, with even greater force when pus is secreted in a similar cavity, 
excepting always those cases in which the removal of pieces of bone complete- 
ly loosened by the accident, give a ready outlet to the fluids beneath. When 
blood is effused beneath the dura mater, into the serous cavity of the cranium, 
if it is arterial, it rarely distributes itself very widely, but is frequently circum- 
scribed by adhesions; if, on the contrary, it is venous, it may spread over a greater 
space before it coagulates. When the quantity is small it may be absorbed^ 
when large it produces symptoms, the gravity of which determine the necessity 
of the trephine. The success of the operation depends much upon the con- 
centration of the effusion, but as this cannot be previously ascertained, the ope- 
ration is not less indicated in the one case than in the other, nor when circum- 
stances demand a resort to the measure, does a failure furnish any valid argu- 
ment against its propriety. The serosity which surrounds the effusion contri- 
butes to its fluidity and causes it to spread, in many instances, and when it has 
become solid it is often difficult to remove it; these and other reasons have in- 
duced Sir Astley and Samuel Cooper, Abernethy, &c. to oppose the operation. 
M. Velpeau, while he grants that it is much less promising than in the previous 
instance, still defends it to a considerable extent. He insists only that it should 
not be decided on lightly, " severe symptoms of compression alone justify it," 
in his view. p. 59. Pus similarly situated would warrant the operation if it be cir- 
cumscribed, which is not often the case, but it is altogether contemned when 
the signs of general meningitis are present, although in another part of the 
work, the question of the possibility of relief from extensive trepanning in ce- 
rebral inflammation is represented as perhaps still open to discussion, because 
it is found that the symptoms of such disease in traumatic cases are milder in 
proportion to the extent in which the bones have been removed. 

When blood is thrown out into the substance of the brain, he regards the 
case as almost beyond the reach of surgery, but thinks some good maybe done 
if death does not immediately follow, by using the trephine as a means of giv- 
ing an outlet to the ruptured portions of the brain and the effused fluids, if na- 
ture attempts such an operation, and also to give room for the swelling of the 
brain consequent upon the accident. 

"It results from what I have said, that in traumatic extravasations of the third 
kind, the object of the operation of trepanning should be, less to evacuate the 
blood than to put the organism in a condition to expel it by little and little, to- 
gether with the contused or crushed parts, as inflammation and suppuration de- 
tach them. Acting also in the same manner with the incisions made to remove 
constriction around parts in a state of severe inflammation, it is then the only 
surgical recourse, having some claim to a trial." p. 62. 

In traumatic abscesses of the substance of the brain, and in suppuration from 
wounds of the organ when the outlet is not free, the application of the trephine 



176 Bibliographical Notices. 

is warmly advocated. The rare cases in which patients have recovered from 
such affections after fistulous openings have formed into the nose or ear, after 
caries has been produced, and the numerous instances in which such abscesses 
have been discharged through the opening of fractures, are regarded as proofs 
of its propriety. M. Velpeau seems to advocate puncturing the brain in very 
threatening cases of this character, but in commenting upon an instance in 
which Dupuytren plunged his lancet an inch into the hemisphere, and thus 
reached the cavity, he remarks — 

"If the condition of the patient had not been too pressing, a precaution 
might have been taken, and the surgeon placed more at ease in this case. This 
would have been to wait, after having opened the cranium and the dura mater, 
before going further. It might happen, as in cysts of the abdomen treated by the 
method of M. Graves, (Arch. Gen. de Med.) or in the manner of M. Begin, 
(Journ. Hebdom. de Med.) that the sac distended by the pus, free from all 
compression toward one point, would generally be pushed in that direction by 
the expansive force of the brain. It would then be opened with great facility, 
if not promptly evacuated by the efforts of nature. We should have the advan- 
tage, moreover, by acting in this manner, of soliciting adhesions around the 
orifice made by the trephine, which would greatly diminish the danger of me- 
ningitis, and prevent the accumulation of pus between the dura mater and the 
brain." p. 87. 

He thinks that many patients die from the neglect of the trepan in cases of 
purulent deposits in the substance of the brain; an opinion with which we hear- 
tily coincide? but we may remark that in these cases the removal of a portion 
of bone is of exceedingly little importance unless the dura mater is also laid 
open by the surgeon. We have seen two cases of death after the early employ- 
ment of the trephine^ in consequence of abscess in the corresponding hemisphere 
produced by the contusion of the brain at the moment of the accident. In both 
cases the collections of pus were large, and approached within less than half 
an inch of the orifice in the cranium, but in neither case was the dura mater 
opened, although the diagnosis was clear, and death inevitable without surgical 
aid. Upon what principle is the surgeon excused in leaving such cases to their 
fate? Can he possibly do harm by his interposition? 

In the third chapter the author speaks of '* complex accidents," and considers 
in very few pages the indication or non-indication of the trepan in compressions, 
contusions, concussions, and inflammations of the brain. Under the first head 
there are some remarks with regard to the mechanical forces habitually acting 
on the brain, which are not very perspicuous, but we need not dilate upon these 
sections, for they contain for the most part mere corroborations of the princi- 
ples already noticed. One remark we will extract. 

"Unless it is slight — so slight as to produce but very feeble accidents — con- 
tusion of the brain appears to me incapable of resolution. If it is carried a 
little further, we see it rapidly give place to a pultaceous matter, a true mixture 
of blood, altered tissues, and pus, which collection is not less to be dreaded 
than an ill-conditioned abscess. How is this termination to be prevented or 
obviated otherwise than by the operation of trepanning? If the cranium is 
open, the contused parts may be ejected by little and little, &c." p. 97. 

We cannot forbear one comment upon the prognosis of the operation if per- 
formed for the relief of contusion. The inertia of the whole cerebral mass 
seems to be too much neglected by authors who treat of injuries of the 



Velpeau on Trepanning in Injuries of the Head. Ill 

head. The brain with its membranes is very compressible, in consequence of 
the number and size of its vessels which may be partially evacuated at any 
time by pressure. Now, in falls on the head, when the cranium is instanta- 
neously arrested, the soft and yielding- brain still retains its momentum, and 
would tend to flatten itself against that part of the cranium which first strikes 
the soil, were it not that the encephalon being impervious to air, the brain on 
the opposite side cannot quit its contact with the dura mater, without pro- 
ducing either a vacuum or an extravasation on that side. The former cannot 
occur at all, because the forces required to produce a vacuum are greater than 
those which would suffice to crush the cranium, and the latter cannot become 
considerable until some tinje has elapsed. But the inertia of the brain in mo- 
tion, though it may not separate it from the dura mater, is sufficient to increase 
very greatly its pressure upon that side of the cranium which impinges, and di- 
minishes it to an equal extent at the opposite surface. The necessary conse- 
quence of this double action is, that the blood in the vessels on the lower side 
is suddenly forced out, and that it rushes in additional quantities toward the 
upper side. The brain below is in some degree protected from the contusion 
by the gradual expression of its blood, which, acts as a retarding force; but the 
reaction of this blood upon the coats of the vessels is an additional cause of dan- 
ger at the upper surface. In severe falls, then, which produce no fracture, 
there must always be engorgement and sometimes contusion, and extravasation 
at the point opposite the external injury, even when there is no mischief to the 
corresponding side of the brain, but when fracture occurs there is injury on 
both sides, v/hich, however, may be frequently less important at the wound 
than on the other side of the head. On the contrary, in injuries received from 
bodies in motion, such as stones, canes. Sec. the inertia of the brain has little 
effect, and the contusion and extravasation are almost always found near the 
external wound. In the latter cases the prognosis after operating would be 
more favourable, while in the former, the trephine must be sometimes applied 
on the side opposite the blow, or, (if there be fracture with depression,) on 
both sides, and in either case the chance of success is much diminished. Extra- 
vasations and contusions from this species of contre-coup can very rarely occur 
externally to the dura mater, and therefore their presence is only inferred from 
the nature of the paralysis which supervenes; the uncertainty of the diagnosis 
adds then to the difficulties of the case; yet we are by no means prepared to 
oppose the views of M. Velpeau as to the indications of treatment. 

The author then proceeds to consider the more remote morbid consequences 
of injuries of the cranium, such as fixed pains at the site of the former woundj, 
whether permanent or intermittent, convulsive or tetanic movements, or true 
epileptic paroxysms. When such cases become threatening the trephine should 
sometimes be employed, care being taken to avoid deception from mere ner- 
vous symptoms, and sympathetic affections which may falsely appear due to the 
injury. A considerable number of references to authority are adduced in rela- 
tion to the propriety and safety of operating under such circumstances. 

The fourth chapter is given chiefly to the symptomatology of the several 
classes of injury to the head — irritation, compression, contusion, concussion, 
and inflammation. It contains some interesting remarks, but it is to be regret- 
ted that M. Velpeau has not enlarged this portion of the work so as to present 



178 Bibliographical Notices. 

a more complete view of the diagnosis, particularly in cases of a mixed cha- 
racter. The next chapter treats of the application of the trephine on various 
parts of the cranium. Neither the vicinity of the great sinuses, nor the chief 
trunk of the middle artery of the dura mater, are considered as objections to its 
use. Haemorrhag-e from the former vessels, he thinks, may be readily arrested, 
and that from the latter is not generally alarming. The necessity of involving 
the sutures, or dissecting the temporal muscles, is not held a more serious ob- 
jection, and when circumstances require it he recommends the operator to dis- 
regard the frontal sinus, the occipital and parietal protuberances, and even ad- 
vises the occasional application of the trephine over the cerebelUc fossa and the 
mastoid process. 

Lastly. The dogmatic part of the work is completed by a few remarks on 
the degree of importance attached to the operation of trepanning without re- 
ference to the accidents that demand it. It is treated as a proceeding attended 
with little intrinsic danger, and as by no means severe. That both the difficulty 
and the probable ill effects of the operation have been greatly exaggerated we 
can well believe. According to M. Velpeau, the only plausible objection urged 
against the use of the trephine, when distinctly indicated, is the consequent ex- 
posure of the brain to the air. 

" The idea of Munro, revived by Bell, (Benjamin Bell?) as to the danger of 
placing the serous surfaces in contact with the atmosphere, has taken such deep 
root in the minds of surgeons, that it is almost rash to think of disputing it." 
p. 142. 

Our author does dispute it, and very ably too, though he may be pleased to 
hear that the doctrine has not taken deep root on this side of the Atlantic, nop 
is it by any means so prevalent as he seems to think in Great Britain. 

Of the third part of the work, entitled an " Estimate of Doctrines and Fads ^^ 
we shall have little to add after recommending it to the perusal of all who have 
access to the work. It is a gentlemanly review of the opinions of the most dis- 
tinguished surgeons, occasionally severe, but always fair and candid. In the 
chapter on American facts and opinions, he notices the paper of Professor Eve, 
published in this journal during the last year, the report of cases by Dr. Norris, 
house surgeon of the Pennsylvania Hospital, and the very important communica- 
tions of Professor Dudley, of Lexington, in the Transylvania Journal of the 
Medical Sciences. Beyond these facts, he says, " we find almost nothing upon 
the trephine in the writings published by our profession in the United States." 
p. 192. 

The fourth and last part is given to the consideration of the occasional ulte- 
rior ill consequences of the operation, such as tumours issuing by the opening, 
hernia cerebri, swelling, or what M. Velpeau calls rarefaction of the bone, &c. 
The last-mentioned affection is nothing else but an enlargement of the solid 
portion of bone, affected by the vessels of the bone itself, independently of its 
membranes, and which sometimes produce pressure on the brain long after the 
cicatrix appears perfect, as it did in a case but too well-remembered in this city, 
in which, after recovering from a fracture from a pistol-shot the patient re- 
covered, but died a long time after, from the eff*ects of such a tumour. This 
case is alluded to in the work under notice. 

In taking leave of the reader we recommend the perusal of this treatise to all 



Ogier & Logan's Compendium of Operative Surgery. 179 

American surgeons, not for its originality, but for its candour. It is rich in in- 
teresting cases and references, and appears to establish most completely many 
of the principles advocated. We cannot go the quite full length with M. Vel- 
peau in recommending the trephine in certain cases, but we firmly believe that 
those who read his remarks will be prepared to act with more decision than is 
now customary in cases of injuries of apparently desperate character. There 
is one principle advocated by some very distinguished men in this country, 
which is sometimes applied, by their juniors at least, in a manner deserving of all 
reprobation — it is this, that a dangerous and extremely doubtful operation is to be 
avoided in many cases, simply because the failure may compromise the reputation 
and destroy the usefulness of the surgeon! This feeling, to our certain know- 
ledge, has prevented the use of the trephine in many cases in this country. Now, 
though we are no ardent lovers of mutilation and the knife, we never witness a 
surgeon in debate upon a case involving the certain loss of life, if left to nature, 
and making out his opinion of the indications by casting his reputation into the 
scale, but with a kind of nervous shudder and certain reminiscences of a court 
and jury. R. C. 



XXI. A Compendium of Operative Surgery^ intended for the Use of Students, and 
containing a Description of all Surgical Operations. Illustrated with Engravings, 
No. 1. By Thomas L. Ogier, M. D. Lecturer on Anatomy and Operative 
Surgery, and Thomas M. Logak, M. D. Lecturer on Materia Medica and The- 
rapeutics. Charleston, 1834. pp. 262. 

A suitable manual of operative surgery, illustrated by plates, and adapted to 
the state of the art in this country is very much wanted, and we took up this 
Jittle faciculus in the hope that it would pi'ove the commencement of such an 
undertaking; but candour compels us to confess that our hopes have not been 
altogether realized. 

The first number, the only one yet published, treats of the various forms of 
incisions, and the mode of handling the knife in performing them, the several 
varieties of suture, the different species of ligatures, the mode of tying the tem- 
poral and facial arteries, and the operation suggested by M. Manec for securing 
the lingual artery. In the introduction, the authors acknowledge the extent 
to which they have used the well-known v/orks of MM. Manec, Coster, Velpeau, 
Sabatier and Blandin, and indeed the whole aspect of the number is pecu- 
liarly French. Waving all remarks upon the rules for holding the instrument 
and making incisions, not because they are perfect and unexceptional, we may 
notice that the bistoury is the instrument described as appreciable to almost all 
cases, and little more than a bare allusion is made to the scalpel, while as it 
is well known the instruments generally called by the former name are scarcely 
ever used in this country, except in punctures, in cutting from within outward- 
ly, in laying open fistulae, or in dividing parts upon the grooved director. The 
broad bistoury figured in the first plate, and fitted for great incisions, is an in- 
strument which we have never seen employed. The English scalpel placed 
beside it, with the steel continued through the handle, and terminated by a 
rasperatory is only seen in trepanning cases, and this particular specimen 
with its acuminated point, has a form very ill-adapted to the uses to which 



ISO Bibliographical Notices. 

the scalpel is usually devoted. Moreover, the long-, conical director which 
always reminded us of the apparatus major, is miserably adapted to the end for 
which it was desig"ned. Notwithstanding- the many excellencies of French sur- 
gery, it may be remarked in perfect fairness, that the French were never noted 
for the excellence or beauty of their instruments. It is difficult to avoid the 
question, whether the authors could furnish the originals of these drawings 
from their own cabinets. 

The crucial, the V, and the T incisions are all directed to be made with the 
bistoury, and the directions are adapted to that instrument only, but the authors 
acknowledge that the elliptical incisions should always be made with the 
scalpel. So, we think, should the others, unless under very peculiar circum- 
stances. 

In the description of sutures, no notice is taken of the fact that the interrupt- 
ed and twisted sutures are almost exclusively used in this country. The quilled 
suture is an excellent resource in very extensive incisions, particularly on the 
abdomen, and the looped suture may possibly have its applications in some of 
the operations for the cure of deformities; but the glover's suture! — what doth 
it here ! However, we believe it was once used after a very celebrated ovarian ope- 
ration in New Jersey y performed hors de la profession. There is one objectionable 
circumstance in the plate representing the several sutures. In works designed as 
manuals for beginners, care should be taken that the illustrations of treatment 
should represent the remedy as applied in cases demanding its use; now, if we 
except the hare-lip, and possibly the wound of the nose, none of the incisions 
figured in the plate require a suture at all. This may be regarded as hypercriti- 
cism, but the first impressions made on the mind of a beginner are exceedingly 
important, and the matters of which we are speaking are purely elementary. 

In speaking of the different modes of arresting haemorrhage, the authors, we 
were astonished to find, make use of the following sentence. 

"To arrest haemorrhage during operations on the extremities, surgeons for- 
merly used the tourniquet, which is so perfectly familiar to every one that it is 
useless to describe it here. Its application being very painful to the patient, it 
has fallen very much into disuse in France. In England and America it is occa- 
sionally used, though not so often as formerly." p. 18. 

The substitute mentioned is, of course, pressure by the thumb of an assistant 
on the principal artery of the limb. We cannot but esteem the authors mistaken 
on the facts of the case, but as it regards the expediency of the substitution, 
under circumstances which admit of a choice, we differ with them most decid- 
edly, and feel confident of support in our opinion from four-fifths of the pro- 
fession out of France, and from no small number in that country. Though 
pressure on the inguinal artery may not be very painful, it does not perfectly 
command the circulation of the limb, and certainly pressure on the subclavian 
is vastly more painful than the tourniquet, while it requires some skill in the as- 
sistant, and when the patient is restless, or the operation protracted, it is ex- 
ceedingly insecure. 

The authors advocate the torsion of the smaller arteries in preference to the 
ligature. We have so recently spoken of this plan of treatment that it is unne- 
cessary to repeat the remark. (See Bibliograph of Sanson on Reunion in this num- 
ber.) They mention the different forms and materials for ligatures, but take no 



Gerard in & Gaimard on Cholera Morbus. 181 

notice of the almost total condemnation of the flat ligature, and the scarcely less 
universal abandonment of animal ligatures in the country of their birth. Allusion 
is made to the beautiful forceps of Dr. Physick, for securing deep-seated arte- 
ries, and a figure is given in illustration, but by some strange misconception 
the needle is fixed in a position the reverse of the true one, thus depriving it 
of almost all the -advantage derived from the forceps, and making it scarcely 
applicable to any artery beyond the reach of the needle alone! 

We might make some further strictures, but the task is disagreeable. Some 
of those already made, fall most heavily upon the authorities from whom the in- 
struments and measures censured are derived: but as these latter have been 
adopted in aR American book, designed for the use of American students, we 
have felt it to be our duty to notice them more pointedly than we should have 
done had they been presented to us in their original dress. Doubtless the 
details of the more important operations will be much more interesting and 
valuable as the work proceeds. Wishing it success, we would only suggest, 
in closing these remarks, that it might be adviseable to draw the instruments 
from such as are in actual use on this side of the Atlantic, and which have 
therefore undergone the last improvements of Yankee ingenuity. R. C. 



XXII. Du Cholera- Morbus en Russie, en Prussie et en Auirldie, pendent les annees 
1831 et 1832. Par M. M. Augusts Gerardin et Paul Gaimard, Membres 
et Commissaires de 1' Academic Royale de Medecine, Envoyes en Russie 
par le Gouvernement Frangais, pour Etudier le Cholera. Deuxeme edition. 
Avec trois Planches graveeset coloriees, Sec. &c. Paris, 1832. pp. 340. 8vo. 

This volume comprises ten letters addressed to Count D'Argout, Minister of 
Commerce and Public Works of France, by the commissioners sent to Russia 
to study the cholera; with an appendix, consisting of an account of the plague 
of Moscow in 1771, compared with the cholera which prevailed in the same 
city in 1830 and 1831, together with various official documents relative to the 
progress of cholera, sanitary cordons, &c. &c. 

The first nine letters are principally devoted to an account of the progress 
of cholera in the north of Europe, and of the means taken to arrest its march 
by sanitary cordons, with abundant illustrations of the futility of these measures, 
and even of their absolutely injurious tendency. We have, on a former oc- 
casion considered these subjects, (see No. for May, 1832,) and shall not now 
again discuss them; the more especially as subsequent observations have not 
led us to alter the views already presented. The tenth letter in the work be- 
fore us is devoted to the consideration of the symptoms, anatomical lesions, and 
treatment of cholera. 

The symptoms of this disease are unfortunately too familiar for it to be ne- 
cessary to repeat what is said by our authors on this subject; but we must not 
pass by in silence the interesting chnical experiments of Dr. Czermak, Pro- 
fessor of Physiology in the University of Vienna, respecting the low tempera- 
ture of the body, a constant attendant on this disease. From the experiments 
alluded to, it results — 1st. That the feet are constantly found to have the lowest 
temperature, next the hands and the tongue, then the body, neck, scrobiculis 
No. XXIX.— November, 1834. 16 



132 Bibliographical Notices, 

cordis, &c. (MM. Gerardin and Gaimard state that in the experiments made by 
themselves, the tip of the nose was found to be colder than the feet, whilst the 
region of the heart and the arm-pit was always the warmest.) 2d. That the 
temperature of the feet was as low as 14° R. and that of the tongue 15° R. 
Consequently there is no disease in which the temperature of several parts of 
the body descends so low as in cholera. In fainting-, lypothymia, and the chill 
of intermittent fevers, the temperature of the body is never lower than 22*^ 
R. 3d. That the temperature may be of great importance in aiding our prog- 
nosis. In fact, no example of cure has been cited in which the temperature 
was below 19° R. and the higher the temperature was above this, the more 
favourable, c?eteris paribus, is the prognosis. 

We must also quote the following experiments of the same learned professor, 
relative to the temperature of the blood, compared with that of the other parts 
of the body. These experiments were made in a room, the temperature of 
which was from 15° to 16° R. and the blood examined was always drawn from 
the arm. 

f Tongue 23i° R. 

1st. Woman, set. 27. J Hands 21^ 

Cured. ^ Feet 19| 

LBIood 24| 

2d. Woman,^t.39. SS^'T^ iqI 

ni^d < Hands 19| 

^'^'^- CBlood 20i 

fTongue 24f 

3d. Woman, ^t. 54. ^ ^ll^\ \ \ \ \ \ '_ ^f 

Cured. . gcrobiculis cordis .... 25 116 

LBlood 26 1-6 

4th. woman, .t. 21. ^^-§- ." ; ; ; -. '_ ^3 

"'^'^- CBlood 21| 

5th. Woman, ^t. 62. ^^°y^^"^^^'^^P^'^^ " " " ^^! 

^^^^^- Ibw ". ■ " ■ - " 22I 

6th. Man, ^t. 48. ^Hands^ ::;::: 22t 
^'^^' ^Blood 26 

7th. M.,,^ 60. e-r :::::: III 

<=^^^^^- ^Blood 27 

8th. Man, .t. 32. ^^r :::::: f,, 

^^^^- ^Blood 21| 

One of the most interesting points in the history of cholera, is the changes in 
the composition of the blood 5 and our authors have collected some valuable in- 
formation on this subject. M. Hermann, professor of chemistry at Moscow, 
found the blood of a young man in good health, to contain 43 parts of coagu- 
lum, and 57 parts serum, the latter having a specific gravity of 1.027. In per- 
sons labouring under cholera, the normal proportion of these constituents of the 
blood are always different; the quantity of the first being always increased, and 
that of the latter diminished. Moreover, what is very remarkable, and this ob- 
servation has been amply confirmed by subsequent analysts, the proportion of 



Gerardin & Gaimard on Cholera Morbus. 183 

coag'ulum increases with the violence of the disease, so that it attains its maxi- 
mum just before the death of the patient. When the patient recovers, there 
is observed an alteration in the composition of the blood, progressively dimi- 
nishing-. The proportion of the constituents of the blood, according to the in- 
tensity of the disease was in 100 parts — 

Coagulum, 50 55 60 60.3 62.5 
Serum, 50 45 40 39.7 37.5 



100 100 100 100 100 

The blood of a patient who had had cholera, and who was afterwards attack- 
ed with a febrile paroxysm, presented the following proportions. — Coagulum, 
44.25^ Serum, 55.75 = 100. The proportion of albumen in the serum also 
augments in proportion to the intensity of the disease, and attains its maximum 
just before death, as is proved by the following experiments of Professor H. 
The specific gravity of the blood of a person attacked with cholera at the onset 
of the disease before he had had any watery evacuations was 1,027, the specific 
gravity of the blood of a healthy person as just stated. But as soon as this 
crisis occurred, the quantity of water in the serum commenced to diminish? the 
specific gravity of the blood increased to 1.028, subsequently to 1.032, and 
blood drawn from a patient four hours before his death, was found to be 1.036. 

These observations on the alterations in the proportion of the constituents of 
the blood, are confirmed by the experiments of M. Wittstock of Berlin. He 
has found, that when the blood taken from the right ventricle of persons who 
had died of cholera, was carefully dried, 30 per cent, of solid matter was al- 
ways obtained, whilst in health, blood only yields 21 per cent. This skilful 
experimenter, alsofoundthe serum of the blood of a man aged twenty years, who 
died of intense cholera, to have the specific gravity of 1.0447, and to yield on 
evaporation 16^ per cent, of solid matter. The blood was drawn by bleeding 
some hours before death. In a young woman in good health, M W. found the 
specific gravity of the serum to be 1.028, and this liquid to yield 9^ per cent, 
of sohd matter. The serum of a cholera patient who was cured, yielded 14^ 
per cent, of solid matter, and its specific gravity was 1.041. 

The fluid of the alvine dejections, it is stated, were found to be very alka- 
line, to become opaque by the action of heat, and to be rendered turbid on the 
addition of corrosive sublimate, showing that it contained much albumen. The 
repeated analysis of the dejections in the hospitals of Berlin, are said to have 
always given the same results. These results are the reverse of those obtained 
by Dr. Twining of Calcutta, who states that he found the conjee stools not co- 
agulable by heat. 

The following is a summary of the lesions observed in cholera, as given by 
our authors. 

" The more rapidly fatal the disease proves, the less constant, marked and 
identical are the cadaveric lesions; sometimes even there is no appreciable 
disorder. This absence of all lesion, however, is an evident proof, that the 
derangement of the system of inervation ought to be considered the first and 
most important.* 

• The correctness of this last proposition might be contested; and we think, controverted. 



1^4 Bibliographical Notices. 

"The afflux of blood to, or the active congestion of the intestinal canal, appears 
to be especially concentrated upon the mucous membrane of the small intes- 
tines. This membrane is tumefied, spongy, impregnated with a whitish fluid: 
the exudation of which it is the seat, at first clear and watery, becomes more 
consistent, and lines the internal surface of the mucous membrane with a floccu- 
lent or gelatinous substance, very similar to a pseudo-membrane.* This exuda- 
tion is sometimes traversed by very fine capillary vessels, which are particu- 
larly observed at those points which adhere most firmly to the intestine. 

** To thisseriesofphenomenathere is joined, the suppression of the urinary se- 
cretion, and doubtless also, that of the pancreatic liquor; the bile retained in the 
gall-bladder, no longer flows into the ahmentary canal: then, either the plasti- 
city of the secretions increase, and the alvine discharges are moderated; or, 
what is frequently the case, the albuminous lymph secreted remains suspended 
in the intestinal fluid, in the form of white flocculi. 

"In consequence of this intestinal exhalation, the mucous membrane swells, 
and resembles a very fine porous sieve: its valves, especially those in the jeju- 
num, become flaccid and floating, and of from two to three lines in size. 
The tissue of the intestine is of a rose colour; glandular, tubercular bodies of 
various sizes are developed, especially in the lower convolutions of the ileum^ 
We will presently describe the structure of these recently -formed bodies. 

" The dejections composed of a bloody water, mixed with brown or reddish 
flocculi, indicate in general the approach of death. In this case there is found 
a considerable softening of the mucous membrane, especially of the middle and 
lower portion of the small intestines: this membrane is of a grayish-red, and ap- 
pears infiltrated with water and bloody mucus; moreover, we find that the ex- 
tremities of the vascular ramifications are free and as if open on the surface of the 
intestine; by slight friction small cylinders of coagulated blood may be pressed 
out of them. If the disease has been very violent and promptly fata], there is 
often observed ecchymoses and even very extensive sanguineous effusions, 
which extend over entire convolutions of the intestine. 

*' These alterations progressively diminish in the mucous membrane of the cce- 
cum and colon, so that this membrane is found only relaxed, coloured in many- 
places of a bluish-red, and covered in places with small tubercles which more 
rarely unite forming plates." pp. 134-7. 

These different alterations have been observed by the German physicians, 
and particularly by the learned professor of pathological anatomy, at Vienna, 
Dr. Wagner. The granulations and plates, our authors think, should not be 
considered as causes, but as accidental effects of the disease, since they are not 
constantly found in cholera patients, and analogous though less marked alterations 
had been observed at Vienna several months before the appearance of cholera. 
The granulations and plates just noticed do not consist, it appears, of enlarged 
glands of Brunner and Peyer. In fact, this kind of tuberculiform eruption ex- 
ists not only at the lower part of the small intestines and commencement of the 
coecum, but is met with in the stomach, oesophagus, and even in the tongue. 

* We have been shown by our friend, Proftssor Horner, a portion of the small intestine of an indi- 
vidual who had died of cholera the present autumn at the Philadelphia Alms-IIouse, completely linecj 
with this pseudo-membrane, and which in every respect resembled the membrane sometimes found 
liningthetracheaofthose who die of croup. We are promised for a future No. an account of the ye* 
searches of the distinguished anatomist just spoken of, into the anatomicallesions in cholera. 



Gerardin & Graimard on Cholera Morbus. 185 

Professor Czermak, and his adjunct, M. Hyrtz, have made some minute injec- 
tions and microscopical observations in order to discover the nature of these 
lesions, and the results of their investigations show, according to our authors, 
that the alterations in question are not erosions, for there was no extravasation 
of the matter of the injection. This matter passes easily into the folhcles of 
Brunner and Peyer, but not into the tuberculiform bodies; but the intestinal 
villi are more readily injected than in other bodies: these injections are also 
made as readily, and even more easily by the veins than by the arteries, in 
cholera patients. But if the lymphatic vessels are injected, the tubercles 
and plates regarded as erosions are equally filled; whence it results that 
these tubercles and plates result from the development of the lymphatic vessels, 
so well described by Hedwig, Rudolphi, &c. 

Our authors state that they saw in Russia and in Prussia, in many post mor- 
tem examinations, and at Vienna in numerous preparations preserved in spirit 
of wine, at the lower portion of the small intestine, elHptic or spherical plates of 
the diameter of from half an inch to even two inches, the surrounding villi being 
normal, whilst those at the circumference of the plates were more developed, 
showing the size of these plates. Sometimes the development of these villi, 
as they changed to form the plates, could be distinctly observed. A beautiful 
coloured plate illustrative of the lesions we have noticed is given. 

Much interesting information has likewise been collected by our authors, re- 
lative to the remedial powers of various measures proposed for the cure of the 
disease in question. When the disease first invaded Europe many ph3'sicians 
thought that the disease was a form of malignant intermittent fever, and that it 
might be cured by bark. Unfortunately, experience has not justified this hope, 
and after the numerous trials that have been made with this remedy without suc- 
cess, our authors think themselves justified in confidently advancing it as an 
axiom, that — 

*' Bark and its preparations administered with the viev/ of treating algid cho- 
lera as a malignant intermittent have not produced the beneficial effects which 
were expected." 

Other practitioners with the view of arresting the evacuations resorted to 
opium and its preparations as the basis of their treatment; but these were found 
according to our authors to increase cerebral venous congestion, and they 
were finally proscribed in Russia, Prussia and Austria. 

The physicians of the north of Europe believed that they could arrest the af- 
flux to the digestive organs, by exciting an active derivation to the external 
surface. With this view they resorted to vapour baths and frictions. The pa- 
tients surrounded with vessels filled with hot water, parched oats, hot sand, 
&c. ; and hot drinks were administered. The result of these measures, for the 
most part, was to precipitate the progress of the disease. Hot drinks increased 
the changes, rendered the thirst inextinguishable, and produced renewed eva- 
cuations; the different articles and numerous coverings with which the patients 
were overburdened, were so insupportable, from the uneasiness, anguish, and 
inexpressible anxiety which they determined, that the dying summoned all 
their strength to relieve themselves from them. These measures in all instances 
exhausted the strength of the patients, and destroyed the little vital energy 

16* 



186 Bibliographical Notices. 

which lead to or induce the period of reaction. Vapour baths were particularly 
employed in Russia, but their utility was considered so doubtful that their use 
was abandoned in Prussia and Austria. In France, England, and in this country, 
where these measures have been subsequently employed, their inefficacy and 
even injurious tendency have been fully recognised. Had the practitioners in 
these latter countries taken proper measures to ascertain the results of experi- 
ence elsewhere, much suffering might have been spared to cholera patients. 

As to the various stimulants, our authors state, that — 

" All practitioners agreed in regarding them as often inefficacious, and 
still more frequently as aggravating the symptoms they were given to re- 
lieve." 

The mode of treatment which seems to have united in its favour the most 
eminent practitioners of the north of Europe, is that by emetics and cold. The 
following was the method of treatment pursued at the temporary hospital of 
Aboukoff at St. Petersburg, and by means of which cures were effected which 
often struck our authors with astonishment. 

"As soon as the patient entered the hospital he was placed in a bath of from 
28° to 30° R. (95° to 100° Fah.) and retained in it for half an hour or an hour; 
he was then placed in a warm bed and rubbed all over with ammonia, whatever 
might be the intensity of the disease. A draught, containing four or five grains 
of emetic, was immediately administered in divided doses, and at shorter or 
longer intervals. As soon as the action of the medicine became manifest, the 
nature of the matters vomited changed; they became better, and presented 
a bilious and poraceous aspect. From this moment the cholera vomiting ceased 
and rarely returned; the diarrhoea was arrested, or much diminished; finally, after 
some hours the symptoms of reaction were progressively manifested; in a word, 
the algid cholera was changed to febrile or inflammatory cholera." p. 149. 

Our authors have presented in much too favourable a light the results of the 
above treatment. Thus they state that of 313 patients treated by the above 
method, 231 were cured, or 74 per cent, which is extraordinary success in cho- 
lera. But it appears from a table joined to the work that the whole number of 
patients received into the hospital of Aboukoff was 626, of which number 122 
were received dead, leaving 504 actually received alive into the hospital, of 
which number 106 died in twelve hours, 85 in twenty-four hours, 55 in three 
days, 14 in six days, 13 in ten days and after; making the whole number of 
deaths 273, and cures 231, which shows the mortality to have been upwards of 
one-half. To make out the favourable results of treatment as given by our au- 
thors, all those who died within twenty -four hours after admission are considered 
as received in the stage of agony, and are excluded, and those only who lived 
beyond the period just mentioned are considered as having been treated. Now 
if those patients alone who are received before collapse, or who live upwards of 
twenty-four hours after being taken under treatment are to be considered, there 
are few hospitals or modes of treatment which cannot boast of great success. 
We do not think then that any evidence has been furnished of great success 
having attended the method adopted in the hospital of Aboukoff, and certainly 
subsequent experience has not induced practitioners to repose any confidence 
in this method of treatment; indeed both the warm bath and tartar emetic appear 
to have been pretty generally abandoned. 



Gerardin & Gaimard on Cholera Morbus. 187 

At Vienna, our authors state, that the ipecacuanha was administered with 
positive success in the different forms of the disease, and at different periods of 
the epidemic. The employment of this substance was not hmited to a particu- 
lar establishment, its use was general in the civil and military hospitals of Aus- 
tria, and every where it is said to have justified the confidence of practitioners. 

"The ipecacuanha was commonly administered in the dose of from 10 to 15 or 
20 grains, at once or in divided doses, according- to the age and constitution of 
the individuals. If in an half hour or hour, this remedy did not operate, it was 
repeated a second or third time; its action being favoured by warming the 
patient and exciting perspiration, (unless it rendered him uncomfortable,) by 
means of dry heat. The limbs were surrounded with flannel or warm cloths, 
and repose and even immobility of the body was recommended. The horizon- 
tal position was preferable to every other. Attentive nurses watched the mo- 
tions and administered to the wants of the patients, who were strictly forbid 
not to rise or leave their beds, for when they did so, as soon as they returned 
to them they fainted and speedily died. Cold drinks, often slightly acidulated, 
replaced with great advantage, the hot and aromatic infusions to which the pa- 
tients exhibited a great aversion; finally, cauterizing sinapisms over the abdo- 
men, over the chest and even upon the neck; frictions with camphorated, vo- 
latile linament, combated with much success, the spasms and cramps in differ- 
ent parts of the body. By the combined employment of these means, algid 
cholera speedily terminated in a return to health, or assumed a second form, or 
that of reaction." p. 158-9. 

The evident success obtained by the use of cold drinks, soon gave rise to the 
treatment of algid cholera by cold. The following is the account of this method 
as employed by Dr. GUnthner, at the great general hospital of Vienna. 

" Cold was employed internally and externally, in the form of water and 
ice. 

"Internally, according as a greater or less degree ©f cold was desired, re- 
course was had to spring water, ice water, and even small pieces of ice. Spring 
water was given by mouthfuls, every two or three m/mutes. Ice was adminis- 
tered in pieces of the size of a hazel-nut, every five or ten minutes. In mild 
cases the degree of cold v/as gradually augmented, but when the disease was 
violent and urgent, the highest degree of cold was immediately used; it was 
continued even during the increase of diarrhoea and vomiting; and when these 
symptoms had ceased or subsided in an evident manner, the intensity of the 
cold was by degrees lessened, until it was at the temperature of water which 
had remained some minutes in a room at the temperature of 12 or 15° Reaumur. 

" When the diarrhoea didnot yield to the use of ice internally, it was stopped 
by one or two injections of cold or ice vi'ater. Externally, cold was employed 
in the form of lotions of cold or ice water, and frictions on the surface of the 
body with pieces of ice. The lotions were applied with sponges or towels. 
The limbs and sometimes the whole body were rubbed with ice until they began 
to grow warm, which most usually occurred in five or six minutes. Then the 
patient was rapidly dried with towels moderately warm in which he was en- 
veloped. Soon and gradually the surface of the body increased in tempera- 
ture; vital turgescence insensibly developed itself, the choleric appearance of 
the face and the spasmodic pains of the inferior limbs was dissipated, perspira- 
tion more or less free, announced that imminent danger no longer existed. 

"In the most violent cases, the more the features of the face were distorted, 
the smaller and more insensible the pulse, the colder and more livid the surface 
of the body, the more violent the cramps of the limbs — the more necessary was 
it to persevere in the internal and external use of cold. In these cases frictions 
with ice were preferable to lotions with cold water. 

"An important remark, which we raust not pass over in silence, is, that the 



188 Bibliographical Notices. 

external employment of ice was always preceded by its internal administration; 
the former was never used alone? moreover when the lotions or frictions were 
discontinued before the body had become warm, precious time bad been lost 
and it was necessary to recommence their employment. 

" A phenomenon of much interest, is the agreeable sensations experienced by 
the patients after this treatment; they ask for and insist on the repetition of the 
otions and frictions, they drink the cold water, and suck the pieces of ice with 
inexpressible delight; they reject with a kind of horror all medicaments. Cer- 
tainly if nature has given to suffering man an instinctive faculty to discover re- 
medies appropriate to the nature of his disease, it can be affirmed that the ac- 
tion of cold is the only one that will always be agreeable to cholera patients, 
and which will invariably be sought by these unfortunate beings even ih their last 
moments. Even when the termination of the disease was unfortunate, it was 
still easy to recognise the energetic influence of this method, by the various mo- 
difications it exercised on the circulation, the colour and heat of the skin, the 
quantity and nature of the excretions, &c. 

"From the middle of September to the end of October a hundred patients 
were treated by this method, of which number, sixty-five recovered, and thirty- 
five died. From the last of October to the 12th of December, forty-two patients 
received this treatment, of this number thirty -four were cured, and eight died. 

" It appears from these authentic documents, that of all the curative methods 
that by cold has proved most efficacious, since nearly two-thirds of the patients 
were cured by it, a proportion of cures not yet obtained in any other country. 

" The employment of cold has also other advantages. Whilst hot drinks ex- 
cite only disgust, increase the thirst, and in place of relieving it, produce an- 
guish and agitation; cold drinks, on the contrary, gratify the wishes of the pa- 
tients, render them calmer and more docile. These drinks also supply rapidly to 
the system the losses caused by the excessive evacuations." 

Under this treatment a prompt cure is often obtained; but in violent cases, 
an inflammatory state supervenes, most frequently congestion of the brain and 
chest. These congestions and local inflammations cannot be ascribed, however, 
to the action of cold, as they supervene after every method of treatment. They 
demand for their cure antiphlogistic remedies. 

The details of six cases treated according to the above method have been 
given by our authors. 

In desperate cases an attempt was made in Vienna to cure the disease by the 
conjoined employment of cold and stimulants; but of fifty-eight cases, nineteen 
only were cured. 

From the space we have devoted to this work, it will be readily concluded, 
that we estimate highly its merits. Indeed, notwithstanding the many works 
which have since appeared on the subject, and the enlarged experience the 
profession has had in the disease of which it treats, this volume may be consult- 
ed with much advantage; and may be ranked among the most valuable contri- 
butions to our knowledge of the terrible scourge which has swept over the 
greater portion of our globe, and is even at the present moment committing its 
ravages in various parts of our country. 



XXIII. General Observations respecting Cholera Morbus. By J. N. Casanova, C. 
M. D. of the Royal College of Medicine of Cadiz. Philadelphia, Carey & Hart, 
pp. 173. 8vo. 

The principal novelty in this work is the recommendation of tobacco smoke 
as an enema in cholera. Dr. Casanova asserts, that — 



Casanova on Cholera Morbus. 189 

*' Out of two hundred and five successful csises which have been treated by 
myself and two other medical friends of Calcutta almost exclusively with the to- 
bacco smoke, there was not one single death." 

We do not feel disposed or prepared, having- no experience with the remedy 
in this disease, to discuss the advantages of this mode of treatment, and will 
therefore submit the question without comment to the decision of the reader, 
upon the testimony, somewhat equivocally expressed, it is true, of the author, 
merely adding that his mode of administering the remedy is as follows: — 

" For the purpose of injecting the tobacco smoke into the intestinal tube, I use 
a patent enema syringe, with iwo cocks instead of valves, to be moved by a 
lever, which performs the same operation as an air-pump, Csiich as those sto- 
mach-pumps made by Maw & Son^ London. J At its bottom end I apply the tube 
to be introduced into the anus, v/hich is to convey the smoke into the intestines: 
at its side end I adapt a large common German pipe, or something like it, but 
of a good size to hold at least four drachms of tobacco finely cut, and a good 
piece of fire on the top of it." p. 170. 

The object of Dr. C, as stated in his introductory remarks, that of making 
himself useful to suffering humanity, is a highly laudable one, but we must sug- 
gest that this object might have been better accomplished had he submitted 
his manuscript to the revision of a competent person, before committing it to 
the press. As the production of a foreigner, writing in a language with which 
he is evidently not familiar, we would be well disposed to overlook '"some pe- 
culiarities of style and arrangement" in the work, but these peculiarities are so 
monstrous, as to deter us in some measure from examining the opinions of the 
writer, being not surie that we clearly comprehend them. We are led to enter- 
tain these doubts, not only from the many inaccuracies of expression, of which 
the brief extracts we have made will furnish examples, but also from the startling 
character of some of the assertions. Thus, among other statements, Dr. C. avers 
that— 

" Having analyzed the blood of many subjects dead of the real cholera moT- 
bus, taken from their bodies from four to twelve hours after death, I have in- 
variably found in it the same proportions of serum as those generally found in 
that of healthy persons." 

Now, this statement, if we rightly understand it, is in direct opposition to the 
observations of every writer we have examined, and positively the very reverse 
of what we have seen ourselves. 



( 190 ) 



QUARTERLY PERISCOPE. 



FOREIGN INTELLIGENCE. 



ANATOMY. 

1. Some Points in the Anatomy ^ Physiology, and Pathology of the Vertebra j 
Column. — The bulletin of the *' Anatomical Society," in the Archives Generates 
de Medecine for March, contains a paper by M. Chassaignac, under the above 
title, which is worthy of notice, and of which the following is the substance: — 
^ In this paper M. Chassaignac draws the attention of the " Anatomical So- 
ciety" to the existence of certain osseous tubercles, situated at the base and 
behind the transverse processes of the lumbar vertebrae, on the same line with 
the articular processes, but a little below them. These little tubercles present 
the appearance of a mamellated process, especially in the two last dorsal verte- 
bra;, and serve as points of attachment to the tendinous slips of the longissiraus 
dorsi muscle, which has been erroneously described as attached to the articu- 
lar processes. 

The sixth cervical vertebrae also presents another tubercle, which we find, 
but in a less marked degree, in the other vertebra of the neck. This tubercle 
is placed in front of the transverse process, and is the more prominent as the 
individual is advanced in age; it varies considerably, both in size and form, 
in some subjects being nothing but a simple osseous slip? in others forming a 
perfect hook, with the concavity turned forward. This process corresponds 
with the primary carotid artery, which is placed in front, and a little to the 
inner side of it, and furnishes so certain a guide to the vessel, that by placing 
a finger on the eminence, we may plunge a scalpel into the artery with the 
eyes shut, without any previous incision. In consequence of this connexion, 
M. Chassaignac has given it the name o^ carotid tubercule. The process can be 
easily felt through the integuments, at least in the dead body, being only cover- 
ed by the skin, subcutaneous muscle, cervical fascia, and exterior edge of the 
sterno-cleido-mastoid muscle. To find it, v/e have merely to extend the neck 
slightly, and press the finger on the inner edge of the above-mentioned muscle, 
two inches above the clavicle; at the same time we should be careful that the 
neck is perfectly straight, for the least rotation is enough to alter the relations 
between the artery and tubercle. In the living body the process is not so easily 
discovered, in consequence of the greater resistance given by the subcutaneous 
and sterno-mastoid muscles. 

In an anatomical point of view, the tubercle of which we speak serves to 
distinguish the sixth cervical vertebra from all the others, and to determine in 
a positive manner the situation of diflTerent organs in the cervical region. As 
applied to surgery, a knowledge of this process may serve to direct us with the 
greatest certainty to the primitive carotid, and in this respect is analogous to 
the osseous tubercle on the first rib, close to the edge of the subclavian artery. 



Anatomy. 191 

It also presents a surface well fitted as a point d'appui to compress the vessel 
in cases of sudden haemorrhag-e. In the case of a penetrating wound, with hs- 
morrha^e, inflicted in the neighbourhood of this process, the blood may come 
either from the primary corotid, from the inferior thyroid, from the vertebral 
artery, or from the posterior or ascending" cervical branches. The relations of 
these different arteries with the process in question may serve to determine the 
precise source of the haemorrhage, a question otherwise extremely difficult to 
resolve. It is immediately below this process that the vertebral artery penetrates 
into the canal of the cervical vertebrae; the posterior cervical is below, and a 
little external to it; the inferior thyroid, crossing behind the carotid artery to 
gain the thyroid body, is also very close to it; the tubercle will, therefore, serve 
as a useful point de depart for the exploration of the surgeon when about to 
apply one or more ligatures. Should any difficulty be experienced in seeking 
this tubercle through the integument, it is immediately obviated by a division of 
the skin and superficial layer of tissue. — Lancet y May 2Uh, 1834. 

2. Communication of the Optic Nerves. — M. Nelatois- has exhibited to the 
Anatomical Society of Paris a curious alteration of the commissure of the optic 
nerves in a person whose vision had not offered any sensible anomaly. The 
central portion of the commissure was degenerated into a gelatinous matter; on 
each side the optic nerves ran their course parallel, and communicated only by 
a nervous loop at the anterior border of the commissure. This interesting and 
probably unique specimen supports the opinion of M. Cruveilhier, who thinks 
that if there is any decussation of the optic nerves, it is only at the centre of the 
commissure; but in this specimen the nervous loop, a species of anastomosis con- 
stitutes a new mode of communication not hitherto signalized. — Archives Gen. 
February i 1834. 

3. Situation of the Decussation of the Anterior Cords of the Medulla Oblongata 
in Relation to the Occipital Foramen. — The situation of the decussation of the 
anterior cords of the medulla oblongata is well known, but its position in rela- 
tion to the occipital foramen was disputed, some conceiving it to be above, others 
below this opening. The question having arisen in the Anatomical Society of 
Paris whether compression on a level with the above-mentioned foramen would 
produce paralysis of the opposite side, a committee consisting of M. M. Bekard, 
Chassaignac and Montault, were appointed to clear up the point, and they 
have ascertained by various experiments, that this decussation in reality is si- 
tuated above the occipital foramen. This is a very important fact in relation 
to the diagnosis of lesions of the spinal marrow. — Ibid. 

4. Nerves of the Hand. — M. Camus has communicated to the Anatomical 
Society of Paris a very interesting memoir on the distribution and termination 
of the nerves of the hand. He has shown the existence of gangliform corpus- 
cles, annexed to the terminations of the nerves on the palmar face of the hand. 
These nerves are the only ones which have these appendages. Some of the 
members of the society doubt these small bodies being nervous; their exist- 
ence is not however the less remarkable and interesting. — Ibid. 

5. Hermaphrodite. — This curious freak of nature is thus described in the 
Liverpool Medical Journal for July last. " It is a native of Saxony, the only child 
of an officer in the Prussian army, and born in wedlock. The voice and fea- 
tures were those of a man, and the height apparently about four feet nine 
inches. A light, downy beard covered the upper lip; the mammae were not 
developed, and the chest was destitute of hair. The interpreter who accom- 
panied the victim of this extraordinary freak of nature, stated that he was thirty- 
four years old, that at birth he was considered to be a female, and that he 
always dressed as such, and wore his hair turned up until little more than twelve 



193 QUARTERLY PERISCOPE. 

months ago, when, in consequence of Professors Bhimenhach at Gottingen, 
and Tiedemann at Heidelburg-, having- some time previously told him he was a 
man, he assumed the male attire. 

On examining" the org-ans of g-eneration, no penis was to be seen, but the 
scrotum was discovered, divided along the median line, the two halves resem- 
bling the externallabia of the female, somewhat pendulous, and each containing 
a testis. The part corresponding to the mans veneris was not very well deve- 
loped, and was moderately supplied with hair. On separating the halves of the 
scrotum, (or labia externa,) the glans penis came into view, resembling a 
large clitoris, and in the natural situation of the latter organ. It was covered 
with a prepuce, and had a fissure below, which was imperforate. About an inch 
lower dov^rn, and nearly half an inch to each side of the raphe, were two very 
small orifices, resembling abrasions of the membrane, and hardly admitting the 
point of a probe. Still lower was situated the entrance of a pretty capacious 
canal protected at its lower edge by a fleshy bridle somewhat of a semilunar 
form, which divided it from the perinseum. This canal was about three inches 
long, and terminated in a cul-de-sac, excepting that at the further end there 
was a narrow orifice, through which, when he was desired to make water, the 
urine flowed. The right scrotal half, (or labium,) contained a reducible hernia, 
for which he was operated on by Professor Bach, at Dresden, three years ago, 
when it first appeared. The testes descended, for the first time, along with 
the liernia. The cicatrix left by the operation is still visible on the left labium, 
and he wears a double truss. 

He has pretty strong sexual desires, and says that he can perform in either 
character, but prefers jouer le rule de la femme. He has nocturnal emissions, 
and emissions also on libidinous ideas being excited with regard to either sex — 
the semen flowing from the small orifices below the clitoris or glans penis. 
There was never any discharge resembling the catamenia. 

This individual, as Dr. Sillar explained to the gentlemen in attendance, be- 
longs to the fourth class of Sir Everard Home's division, fPhil. Trans. 1799,) 
viz. *' where there exists a real mixture of the organs of both sexes, although 
not sufficiently complete to constitute the double organ." 



PHYSIOLOGY. 

6. Experiments upon the Sounds of the Heart. — M. Majeitdie having recent- 
ly drawn the attention of the Academy of Medicine to the above interesting sub- 
ject, and propounded certain views of his own, which differ most essentially 
from those usually received, in ascribing the first sound to the shock or impul- 
sion of the apex of the heart during its diastole against the thoracic parietes, and 
the second sound to the impulsion of the base of the heart during its systole. 
Professor Bouillaud, who has for many years distinguished himself by his zeal 
in the promotion of auscvdtatory medicine, deemed it proper to have recourse 
to direct experiments similar to those which Dr. Hope performed on asses. 

He laid bare the heart of a strong, full-sized cock, having previously satisfied 
himself by auscultation that its two sounds might be distinctly heard. He then 
listened to its action at first while enveloped in the pericardium, and then when 
divested of it; with the naked ear, and w'ith the stethoscope; and not satisfied 
with one examination, he made several; and the result of these was, that he 
could always hear quite distinctly the double sound, or tic-tac of the heart, al- 
though there was no point of contact between the organ and any part of the 
thoracic walls. The friction indeed of the heart against the end of the stethos- 
cope caused a particular sound; but this sound, (simply one of rubbing,) was 
so very different from the tic-tac of the organ itself, that it is almost quite im- 
possible that they can ever be mistaken for each other. When the heart was 



Physiology. 193 

cut out, by being" separated from its attachments, it continued to beat for a feu'- 
moments; but these beats of the empty organ were not accompanied with any 
perceptible sounds. 

The preceding" experiment was repeated twice upon rabbits with the same 
results; viz. the sounds of the heart were most distinctly heard, althoug-h neither 
during" its diastole nor during" its systole could it come in contact with the tho- 
racic walls. 

In conclusion, the Professor states that the results of his direct examination 
of the sounds of the heart have confirmed him in the opinion that the double 
bruit or tic-tac, which imitates so closely the clicks of a valve, is, in fact, to be 
attributed to the play of the valves of the heart. — Med. Chirurg. Rev. and 
Journal Hebdomadairei No. 9, 1834. 

7. On the Relations of the Cranium to the Organ of Hearing. — Professor Mojox, 
of Geneva, in a memoir read before the Royal Academyof Medicine, on the 25th of 
March last, has sug'g'ested some novel and very interesting" speculations on this 
subject. Hitherto we have been led to view the cranium only as a safe recipient 
of the cerebral mass and of itsappendag-es; but M. M. ing-eniously supposes that 
it serves at the same time as an harmonic case, or drum, to the auditory organs. 
Treviranus, Esser, and others had already observed that the tympanum is not 
essentially necessary to the transmission of sounds, and that the sonorous un- 
dulations may be conveyed to the nerve of hearing by the medium of the cra- 
nial bones; but no one, before our author, had attracted the attention of physi- 
ologists to the curious relations which seem to exist between certain states of 
the cranial bones and the power of discriminating musical sounds. 

The post mortem examination of Dr. Bennati, first suggested to M. M. the 
following speculations, and they arose from Ifis observing that tlie bones of the 
cranium were much thinner than usual, translucent at many points, and soldered 
together along the line of the sutures. 

A similar condition of the cranial bones has subsequently been found by him 
in the body of another celebrated musician. 

This coincidence of cranial attenuation, and musical endowments, led M. 
Mojon to consider whether it was possible that the one miglit be related to the 
other as cause and effect; and he has been induced by numerous observations 
to infer that the cranium is by no means quite passive, in the perception of 
sounds, that differences in the thickness of its walls may have very considerable 
influence in determining the degree of acuteness of the faculty, and therefore 
that it may be regarded as a sort of harmonic case which communicates its vi- 
brations to the organs of hearing. 

In confirmation of these views our author alludes to the cases of deaf people, 
who often can perceive very distinctly the sounds of a piano, or organ, by ap- 
plying one extremity of an iron rod to their forehead, and the other to the in- 
strument; and who may be made to hear what is said to them if only the voice 
is directed by a speaking trumpet upon some part of the forehead. It is not 
unfrequently also that a person whose hearing is indistinct, and who chances to 
wear a wig, can listen with much greater facility when the head is quite bare, 
than when it is covered. 

The curious observations of M. Perler, on patients who had been trepanned, 
and who were found to hear quite distinctly any sound directed upon the 
cicatrix, even when both ears were effectually plugged, (vide our last No.) may 
also be mentioned as illustrative of M. Mojon's speculations. 

Comparative anatomy shows that in a number of animals the transmission of 
sounds to the organ of hearing is assisted by numerous large sinuses, hollowed 
out in the bones of the cranium. To us it seems by no means improbable that 
the musical endowments of the feathered tribes maybe in some degree at least 
modified, or influenced by the very attenuated condition of their cranial bones, 
and by the existence of the elastic lamellae, which are found between their 
No. XXIX.— November, 1834. 17 



194 QUARTERLY PERISCOPE. 

supernumerary cavities, as well as the passages or canals which extend into the 
labyrinth. 

The only practical deduction from the preceding" views, regards the assist- 
ance which may possibly be derived from attention to them, in our diagnosis of 
deafness, when we wish to discover whether it is owing to a palsied state of 
the auditory nerves themselves, or merely to some defect or injury of the ad- 
junct members of the auditory apparatus. The every day occurrence of a person 
squeezing his head with both hands to deaden any very loud noise, may very proba- 
bly effect the desired purpose, as well by interrupting the cranial vibrations, as 
by the direct obstruction of the auditory passages. — Journ. Hebdom. No. 16, 1834. 

8. On the Question of Venous Msorption. By Dr. Ltjchtmans. — Mention is 
made by Hippocrates* and Galenf of absorption and inhalation, which they be- 
lieved were effected in the human body through the agency of the arteries and 
veins. But when Harvey, in the seventeenth century, had fully illustrated the 
circulation of the blood, from which it was plain that the blood was conveyed 
by the arteries from the centre to the periphery of the body, the power of the 
arterial absorption was deservedly rejected.^ Not long after the discovery of 
the circulation of the blood, Casparus Asellius, (anno 1622,) found vessels fill- 
ed with a whitish fluid in the mesentery of a dog, and on the surface of the in- 
testines, which he named lacteals and lacteal veins. Already some idea of these 
had occurred in Herophilus and Erasistratus, (three hundred years before the 
birth of Christ;) and even in the year 1556, Bartholomseus Eustachius saw the 
thoracic duct in a horse, but mistook it for a vein, and called it the white tho- 
racic vein, therefore, many physiologists have assigned the function of absorp- 
tion to these vessels, discovered by Asellius in the first instance; after that Olaus 
Eudbeck, (anno 1650,) more fully demonstrated the thoracic duct, both its 
origin and continuation from the lacteal veins. 

When diligent investigation taught that the lacteal vessels, in appearance at 
least, differed somewhat from the lymphatics, but that this Idnd of vessels was 
commonly dispersed throughout the body, physiologists began to doubt the 
seat of absorption and its apparatus, moreover, to divide into opposite opinions. 
For some regarded venous absorption to be proved by the testimony of the an- 
cients; others thought that this action was to be attributed only to the lympha- 
tic vessels. 

Glisson, Bilsius, and Swammerdam§ are among those who supported venous 
absorption, who, having tied the mesenteric veins in a live animal, and after 
some time having opened them, saw the blood contained in them mixed with 
white striae, and imagined that this matter was absorbed from the intestines by 
the veins. But some explain these striae to consist of coagulable lymph; others 
of chyle not well mixed with the blood, and more or less dispersed through 
the whole body; while Hewson and Rudolph determine that the chyle was re- 
ceived from the arteries. 

It was the opinion of Haller that veins, with the power of absorption, arose 
with small open mouths from the cavities of the body, and the cellular tissue, 
&,c. as appears from various passages in his Elements of Physiology. |1 He also 
derives jaundice from the bile absorbed through the sanguiferous veins. ^ Others, 
as Rosen, Waller, Meckel, Lobstein, and Sir Astley Cooper, have observed, 
that mercury injected into the lymphatic vessels, passed into the branches of 
the vena portse. Tiedemann and Fohmann have found this anastomosis to exist 
in the glands. 

K. Boerhaave (anno 1730) injected water into the stomach and intestines of 
a dead dog, and after continual pressure for several hours, writes that it enter- 

* Epidem. L. vi. t Comment, in Hippocr. Epidem. L. vi. 

\ P. J. Van Maaiien, Diss, de Absorpt. solidoiiim, p. 15. 

\ Vid. Oudeman, Diss, de venarum imprimis meseraicarum fabrica el actione. Gronin. 1792, p. 90. 
H Tom. i. p. 151; torn. vii. p. 47; ubidicit; " Facilis etiam et patula via ab iisdem (meseraicis) veia* 
est in iutestinum," et Tom. vii. p. 89. 
*i Soimnering, de moibis vasorum absoibentium, p^ 122. 



Physiology. 195 

ed the mesenteric and gastric veins, and propelled the blood.* But many per- 
sons, and among- others Dr. Van de Sande,f contend, in order to render this 
argument unavailing", that the water penetrated through the organic pores, or 
through a rupture. J. F. Meckel filled the vesiculae seminales with waxy mat- 
ter, having tied the excretory ducts, and observed this matter penetrate the 
minute branches of the hypogastric vein. So, also, water injected into the 
bladder of a male subject passed into the same vein.± Neither Cruikshank nor 
Dr. OudemaR succeeded in this experiment, wherefore they suppose the inject- 
ed matter passed into the veins through ruptured vessels.^ 

Moreover, others have alleged the deficiency of lymphatics in some parts, as 
in the placenta, which, however, appears doubtful; and that blood efi^used into 
the cells of the corpora cavernosa penis is taken up by veins. || They also ad- 
duce the capacity of the venous system, which far exceeds the arterial, and the 
small dimensions of the thoracic duct, as if it were not sufficient to receive and 
propel all the moisture which is contained in the lacteal and lymphatic vessels.^f 
But even the slower motion of the venous blood corresponds with the greater 
capacity of the veins. 

Here may be mentioned the arguments derived from tying or wounding the 
thoracic duct, such as Haller** and Fiandrinj-j- bring forward, the lesion of 
which animals have survived a long time, seeming to prove that other channels 
exist besides tlie thoracic duct, by which chyle passes into the blood. Never- 
theless, it is evident that these arguments are equally incapable of proving 
venous absorption, since a double thoracic duct has often been discovered. 

Hence it appears that the arguments produced by many of the ancients to de- 
monstrate venous absorption, have not placed ttiis subject beyond all doubt; 
neither do the arguments taken from the incubation of eggs prove more — in 
which veins are present before arteries and lymphatic vessels: for a conclusion 
on so imperfect a state is scarcely tenable with respect to the human body. 

Flandrin was the first who at length studied to recal the learning of the an- 
cients on venous absorption; being urged by the observation, that the blood of 
the mesenteric veins in a horse had a peculiar aromatic odour, and analogous 
in taste to urine, which the blood in the remaining veins in the body did not 
possess. He injected into another horse half a pound of assafcetida, dissolved 
in honey, and smelt it in the venous blood, but not in the chyliferous vessels.+t 
Magendie having succeeded him, instituted the following experiments. He se- 
parated in such a manner a part of the small intestine of a dog, which had been 
previously well fed, that it adhered to the body only by one artery and vein: 
one extremity of this portion being carefully tied, he injected the poison upas, 
and prevented its effusion by a ligature. Death followed as soon as if the poison 
had been introduced into the sound part of the intestine; appearing to him a 
proof that this poison was absorbed by the small branches of the remaining vein. 
Since, however, the slender twigs of nerves probably penetrate the coats of the 
artery, and follow their course, doubts can be started whether these poisonous 
effects cannot be explained by an affection of the nerves themselves. 

He separated the thigh of a dog from the rest of the body, previously stupefied 
by opium, so that only the crural artery and vein remained, having removed the 
cellular coat of these vessels, lest lymphatic vessels might accidentally pass 
through this. He then injected two grains of the same poison into the foot of 
this side; the symptoms appeared as soon, and as powerfully, as when the poison 
is applied to a sound foot.§§ 

• De Perspir. dicta Hippocr. Leidse, 1738. 

t Diss, de Venis lacteis, illaruraque agendi modo. Gronin. 1784, p. 66. 

X Expenmenta et observ. de finibus vasorum, Berot. 1772, p. 49. 

§ Oudeman, i. c. p. 28. 

II Schreger, Fragm. Anat. et Physiol.; fasciculus I. Leipzig, 1793. 

t Oudeman, i. c. p. 115. 

•* Kl. Physiol, torn. vii. p. 68. 

tt L'Esprit des Journ. Oct. 1791, p. 375, seq. 

%% Magendie, Physiol, torn. ii. p. 263. 

§§ Ibid. torn. i. p. 25, seq. 



196 QUARTERLY PERISCOPE. 

The experiments were repeated with the same result by Lawrence and Coates. 
It is, indeed, supposed that the poison was placed in contact with the blood it- 
self, and passed into the circulation by a way made in this direction; but Em- 
mert, in experiments performed uponfrog-s, introduced the poison between the 
skin and muscles, and the same result ensued. It would, however, be difficult 
to show clearly that the application was made without injury to the smaller 
vessels. 

Fodera filled a portion of the small intestine of a live animal with a solution 
of prussiate of potass: having- tied the intestine on both sides, he saw, after he 
had placed the intestine in a solution of sulphate of iron, the lymphatic vessels 
and mesenteric veins ting-ed with a bluish colour.* My most esteemed instruc- 
tor performed this experiment, after the interval of a year, and could only de- 
tect absorption of the prussiate of potass in the lymphatic vessels, but not in 
the veins. The prussiate of potass contained in the portion of the intestine was 
not changed in colour after half an hour, so that the sulphate of iron had not 
penetrated the walls of the intestine. -}- 

According to Tiedemann and Gmelin, colouring, odoriferous, metallic, and 
saline matters, are, in the first place, absorbed by the mesenteric veins; the 
chyle especially, by the lacteal vessels. "White striae were also observed in the 
blood of the vena porta by these celebrated men, which they explain from the 
anastomosis of the lacteal vessels with the sanguiferous veins. Lawrence and 
Coates detected a solution of prussiate of potass both in the chyle and in the 
blood, although more abundantly in the blood;:!^ the contrary was observed by 
the Society of Philadelphia. § 

At length, Mayer injected a solution of prussiate of potass into the trachea 
of a rabbit; he found this sooner in the blood than in the chyle; and in the left 
ventricle of the heart before the right: the same thing occurred, although the 
thoracic duct had been tied; which, indeed, seems to prove that this solution 
was absorbed by veins from the bronchial extremities, but not by lymphatic 
vessels. The same person observed in a man who died from pulmonary affection, 
the veins of the small intestines, at least the minuter branches running- on the 
surface of the small intestine, filled with a gray matter, similar to chyle, which 
were visible to the naked eye even at the margin of the valves of Kerkring. The 
greater trunks contained blood: the lymphatic vessels vi^ere empty, which dif- 
ference he attributed to the venous system living- longer than the lymphatic, 
or from the right side of the heart dying later than the left. 

There is certamly a great difference between the manner in which functions 
are performed, during health, in the living- body, and that in which they are 
exercised, and after vivisections have been instituted, by which, in addition to 
the other injuries, the nervous system, at least in many, is violently disturbed. 
Besides, the substances introduced or applied, in order to illustrate this or 
that physiological question, in the greatest degree differ from the nourishing- 
matter naturally swallowed. Although, therefore, it would be very hazardous to 
apply rashly to the human body all opinions which depend upon experiments, 
nevertheless, we think it can be deduced from the experiments by Mayer and 
Tiedemann, that their opinion is not devoid of all appearance of truth — that the 
power of absorption exists both in the lymphatic vessels, the mesenteric and 
pulmonary veins. 

Another question is added, which has lately been agitated by physiologists— 
whether another passage of the lymphatic vessels into the veins exists, besides 
the thoracic duct alone; either the insertion of several into the left subclavian 
vein, or occasionally into the right; whether, therefore, the power of absorp- 
tion is peculiar to veins — whether they convey what the lymphatic vessels pour 
into the veins by anastomosis. 

* Magendie, Jour, de Phys. torn. iii. p. 80. 

t J. Koker, Diss, de subtiliori membranarum serosarum fabrica, p. 61. 

t Lund. 1. c. p. 65. § Ibid. p. 64. 



Physiology, 197 

Already anatomists have observed, while injecting the lymphatic glands, the 
veins sometimes filled with quicksilver.* It happened to J. F. Meckel, who 
saw mercury had penetrated the vena cava, after he had injected a lumbar 
gland,f which Hewson, Cruikshank, Mascagni, Sec. attributed to ruptured 
vessels. Falconer:{: and J. F. Meckel, jun.,§ have observed the same thing, 
G. Vrolsk relates that he perceived such a communication in the phoca vitulina. 
Beclard affirms he often saw the passage of mercury both in the lymphatic ves- 
sels and the veins of glands, which, however, he did not attribute to the rup- 
ture of vessels. I V. Fohmann, who scientifically investigated this branch of 
minute anatomy, found the same in man; moreover, in horses, cows, cats, &c. 
From many of the glands in dogs the mercury passed only into veins. The 
lymphatic vessels of the small intestine in the phoca marina, appear to terminate 
only in the mesenteric veins; the same obtained in the bronchial gland. 

He also observed in fish, as in the torpedo marmorata, and the esox lucius^ 
an abundant anastomosis between the lymphatic vessels and veins in the neigh- 
bourhood of the heart, and on the surface of the organs subservient to digestion. 

Many observations worthy to be read, on this subject, which have produced 
a similar result, may be found in Lauth.l Even the greater trunks of the lympha- 
tic vessels, according to Lippi, are inserted in man into the renal vein, cava, 
and vena portse. Outside the glands he has even represented, in plates, a horse 
and goose, having this complicated anastomosis; but Fohmann has proved this 
author to have mistaken sanguiferous vessels proceeding from glands, for lym- 
phatic. 

Hence, indeed, it seems to be proved that a communication exists between 
the lymphatic vessels and veins. Granting this to be true, many arguments al- 
leged in favour of venous absorption would be invalidated; for then, to adduce 
an example, the chyle, already in the lymphatic glands, might be mixed with 
the blood in greater or less quantity, by the assistance of the veins. 

It remains for us to notice, that even in our time physiologists might be cited, 
who strenuously deny both absorption of veins, and their anastomosis with lym- 
phatic vessels, among whom Th. Soemmering and Rudolphi are particularly to 
be mentioned; for their injections do not show any passage of mercury from 
lymphatics into veins, neither in the dog, dolphin, birds, amphibious animals, 
nor even in fish; but if mercury should have passed into the veins, they suppose 
it attributable to ruptured vessels. The lymphatics of the small intestine in the 
phoca marina extend to a congeries of glands, which is commonly called pan- 
creas Asellii, the lymphatic vessels proceeding from which converge into a duct 
of marked diameter, to be inserted into the thoracic duct itself; — an observation 
opposed to Fohmann. Rudolphi especially made the following objections to 
venous absorption : — 1. The difference of structure between the lymphatics and 
veins. 2. Fluids injected into the cavities of dead animals are taken up by the 
lymphatics, but not by veins: — which argument does not affect the experi- 
ments instituted in living animals by Tiedemann and Mayer. 3. All odori- 
ferous matters penetrate organs, but are not found in lymphatic vessels, because 
their nature is changed in the glands. Tiedemann found not only odoriferous, 
but also colouring matters, in the blood of the portal veins. 4. He deduces that 
some substances are found in the blood, but not in the chyle, both from peculiar 
causes moderating the absorption of these within the vessels, and from the 
chemical analysis of an organic substance not as yet sufficiently perfect.** 
But if chemical analysis could detect these substances in the blood, I do not 
see why they could not be discovered in chyle, which is as yet imperfect blood, 
and more simple. 5. According to his opinion, matter analogous to chyle ex- 

• Haller, o. 1, torn. 1, p. 177. 

t Nov. Exper. et Observ. p. 7. 

X Experimental Inquiries: London, 1777; p. 46, nota. 

i Lindner, Spec. Med. de Lymphaticorum Systemate, p. 78, 

I Anatomie Generale, 476. 

S Rudolphi, i. c. page 256. ** ibid. 

17* 



198 QUARTERLY PERISCOPE. 

isting- in the blood, was not absorbed at first by the mesenteric veins, but was 
chang-ed into genuine blood during- sang-uification.* 

My valued instructor performed the following- experiment before many pu- 
pils, in order to establish whether the passage of quicksilver from the lympha- 
tic vessels and glands into the veins, was to be ascribed to ruptured vessels: — 
He carefully sought for the lymphatic vessels of the left fore-paw in a well-fed 
dog, which had been quickly killed by prussic acid, and injected with mercury 
a little vessel near the carpus; and pursuing the course of the lymphatic ves- 
sels to the axilla, there we saw a network of lymphatic vessels, conspicuous 
on account of the complicated anastomosis, with distinctly turgid valves, filled 
with mercury. All these lymphatic vessels entered the axillary glands. One 
larger gland, situated near the insertion of the cephalic vein into the axillary 
vein, was entirely filled with the quicksilver, without any rupture of the ves- 
sels or effusion of quicksilver, which could not be so easily detected in the 
other glands or lymphatic vessels. We were unable to discover, by the most 
accurate examination, any other lymphatic vessels going out from the other side 
of the glands; but a vein filled with mercury went out, terminating in the sub- 
cutaneous vein of the neck, which, like the jugular vein, contained mercury. 
A lymphatic vessel going out from another smaller gland, partially filled with 
mercury, appeared to extend to a greater gland. He injected a little mercury 
into a lymphatic vessel of the other foot, and separated it from the body, with 
the gland and veins which proceeded from the other side of the gland, and ter- 
minated in greater veins. We could not detect any lymphatic vessel going out. 
The parts being arranged on a table, he introduced a tube into a lymphatic 
vessel, towards the gland, when, after moderate pressure, we saw by the aid of 
the column of mercury, all the lymphatic vessels of the gland in nodules — not 
only filled, but the mercury soon began to flow from the veins. Upon increas- 
ing the pressure, this vein was turgid with mercury, when a ligature was 
passed round it. We could not detect in this experiment any rupture of vessels, 
after the most accurate examination. At length, having opened the thoracic 
cavity, we saw the thoracic duct turgid with transparent chyle, without a glo- 
bule of mercury; which proves that mercury, in the former experiment, did not 
pass from the thoracic duct into the veins. 

Should any one wish to establish that the mercury passed from the lymphatic 
vessels of the gland by ruptured vessels, after such slight pressure, it would be 
necessary, after the increased pressure, that the mercury should be effused from 
this rupture not only into the vein, but also into the cellular tissue surrounding 
the gland, so as to be extravasated; which was by no means the case. 

Afterwards, an opportunity offering itself through the kindness of the vete- 
rinary professor, Numan, my instructor endeavoured to repeat these experiments 
in a colt. He filled with mercury the lymphatic vessels in the groin, at the os 
humeri, and in the mesentery; but after the mercury had entered the glands, 
an effusion of mercury always occurred from ruptured vessels. After employing 
less pressure, the glands, indeed, were filled with mercury; but the mercury 
neither passed from sound, nor from injured and ruptured glands, into other 
vessels, so that neither the lymphatic vessel going out, nor the adjacent vein, 
was filled. Perhaps the parts were more or less putrefying, from the increased 
temperature of the atmosphere, although no putrid odour was evident in the 
body. If the passage of the mercury from the glands into the veins was the re- 
sult of rupture of the vessels, I do not see why we no where observed mercury 
passing from these glands into veins, but into the cellular tissue between the 
lymphatic vessels of the gland, which was expanded into large vesicles. — Med. 
Gaz. Juney 1834. 

9. Structure and Functions of the Skin. — The Gazette Medicale de Paris, for 
the 8th of February last, contains an analysis of a highly interesting memoir 

* Rudolphi, i. e. page 245. 



Physiology. 199 

presented to the Koyal Academy of Sciences, by MM. Bkeschet and Boussel 
DE Vauzeme, on the structure and functions of the skin. In this memoir the au- 
thors endeavour to estabhsh — 

1st. That there exists in the skin an apparatus for the secretion of sweat, 
consisting" of a glandular parenchyma which secretes this liquid, and of canals 
which pour it out on the surface of the body. These excretory canals are 
disposed in a spiral form, and open very obliquely under the scales of the 
epidermis. 

2d. That the organs of absorption differ in some respect from the lymphatic 
vessels or veins, with which they nevertheless appear to communicate. These 
organs consist of transparent canals, of great fragility, branching or forming 
little arches of communication one with another, but in which we can discover 
no orifice or terminal mouth, which could serve for the purpose of absorp- 
tion. It is this which leads us to believe that this function cannot take place by 
a kind of suction, but rather by imbibition, or by a mechanism, analogous to 
that of endosmose. 

3d. That the medium in which these canals are situated, is a substance produced 
by a true secretion, which being strongly hygrometric, forms a body, by 
the medium of which the phenomenon, which we still call absorption, is effect- 
ed; this absorption is only more promptly and more easily produced on mucous 
surfaces, because on these surfaces, the mucosity, which is analogous in more 
than one respect to an epidermic body, is less dense and more miscible with 
the Hquids which are to be absorbed. 

4th. That the papillary bodies are truly nervous, and the nervous filaments 
which enter in the composition of each papilla, do not terminate, (by bundles,) 
so that each fibril is free and isolated, but the nervous ramuscules appear to 
have terminal arches. 

5th. That the papillae are enveloped in a particular membrane, and in a layer 
formed by the epidermic corneus substance. 

6th. That in these papillae, sanguineous vessels of a much smaller size than 
the nervous filaments penetrate. 

7th. That the different layers of epidermic corneous substances constitute a 
separate apparatus, composed of an organ of secretion and of a substance, at 
first placed in fibres perpendicular to the derma, but which afterwards becomes 
horizontal. These fibres or small stems result from the superposition of small 
scales; and the epidermis, properly so called, is but a part of these stems situated 
at the greatest distance from the derma. 

8th. That in this epidermic substance, formed of scaly stems, are found ab- 
sorbing canals and nervous papillee. 

9th. Finally, independently of the apparatus for the secretion of the corneus 
epidermic substance, there exists in the skin, towards the external face of the 
derma, a small apparatus for the secretion of colouring matter. — Gaz. Med, 
Feb. 8th, 1834. 

10. Passage of Gases through Liquids. — M. Dutrochet has communicated to 
the Academy of Sciences a memoir entitled "On the Endosmose of Gases 
through Water." In a former memoir, in which the author attempted to explain 
the respiration of aquatic insects, M. Dutrochet observed that a mutual change 
took place between the gases enclosed in a cavity immersed in water and the 
external air, the final result of which, was the transformation of the gas contain- 
ed in the cavity into atmospheric air. 

M. Dutrochet saw in this passage of gases in opposite directions through this 
liquid, a phenomenon analogous to that of the passage of liquids through a so- 
lid and permeable diaphragm — a phenomenon similar to that of endosmose. He 
had observed that the gases in this reciprocal exchange passed in different 
quantities, so that according to the nature of the mixture first placed in the 
bell-glass, he could have at the end of the experiment an increase or diminu- 
tion of volume; he also saw that the results varied as the experiment was made 



200 QUARTERLY PERISCOPE. 

in still or running water. The object of his new work is the continuation of the 
researches on this subject. The first apparatus consisted of two glass tubes 
united at the bottom by a third, bent like a horse-shoe. This last tube was filled 
with water, and the two other tubes contained the same up to a certain height. 
The top of the two latter was occupied on one side by oxygen gas, and on the 
other by carbonic gas. After some time the gas passed through the water which 
filled the bottom of the apparatus, so that much carbonic acid was found on the 
side of the oxygen, and a little oxygen on the side of the carbonic acid. Be- 
sides, there was a loss of a portion of the gases, which was dissolved in the 
water, and by far the most considerable part of the loss was of the carbonic 
acid. This experiment, says M. Dutrochet, had not the degree of precision ne- 
cessary; however it served to show me that when two gases separated by a li- 
quid mix, notwithstanding this obstacle, they have commenced to be dissolved 
in the liquid, and it is only when the latter is saturated, that the dry mixture 
commences. This experiment, and others in which the two gases were oxygen 
and azote, show that it is always the most soluble gas in water which passes in 
the largest quantity through this liquid towards the less soluble gas. 

By prolonging sufficiently the experiment with the same gases in an appara- 
tus a little different from the one we have described, M. Dutrochet convinced 
himself that the change continued through the liquid until the proportions of 
the two mixed gases were the same in both receptacles, but there was a result 
he had not anticipated, which was that in the two tubes the mixture was in ex- 
act proportions to constitute atmospheric air. There had been no loss of azote 
but only a portion of oxygen, which was in excess, and remained dissolved in 
the water. The two gases in the passage of inverse directions through the 
water, are, according to M. Dutrochet, in mixture, as are all substances that 
water dissolves simultaneously. 

From this consideration, and others drawn from the phenomena of the mix- 
ture of two liquids of equal viscidity, separated by a partition which exercises 
on them a capillary action, the author is led to establish analogy between the 
capillary action of solids and the dissolving action of liquids. 

The memoir is terminated by observations relative to the influence the state 
of repose or agitation of the liquids, through which the mixture is made, exer- 
cises on the results. 

11. Injluence of Gravity ^ and of a Depending Position on the Circulation of the 
Bloodf in Health and in Disease. — To appreciate properly the importance of these 
influences, it is proper that we attend for a few moments to the condition of the 
circulation in different parts of the body in its most frequent attitudes and postures; 
viz. the vertical or upright, and the horizontal. As the former is the most fre- 
quently repeated and longest continued, it may therefore be reasonably believ- 
ed to exert a more influential operation on the current of the blood than the 
other. Let us consider the effect of the upright position of the body, (and this, 
we need scarcely say, includes the sitting, as well as the standing posture,) and 
we shall at once perceive that the arterial circulation in the inferior extremities 
is thereby facilitated, while the venous circulation is proportionally impeded. 
It is not therefore surprising that as the body advances in years, the operation 
of gravity which is acting constantly, except during sleep, against the venous 
current, should on many occasions induce engorgement of the veins of the leg, 
giving rise to varices, and to obstinate ulcers. The circumstance of these being 
almost peculiar to the lower limbs, can be explained only on the principle we 
have stated. The condition of the circulation through the head is the very re- 
verse; the arterial current has to ascendagainst the gravity of the blood, where- 
as the venous current downwards is favoured by it. Whenever the upright pos- 
ture is changed for another, say the horizontal, the circulation is very percepti- 
bly aff^ected; the veins of the face and neck become swollen and livid, the caro- 
tids and temporal arteries pulsate with greater force, and head-ache and confu- 
sion of thought are often induced. These phenomena are still more rapidly and 



Physiology. 201 

more strikingly developed If the head is lower than the rest of the body. From 
this example we perceive that the veins of the head and neck are nearly pas- 
sive tubes^ their contractile power is very small, no doubt from its being* seldom 
called into play; and hence they become easily distended whenever the current 
of their blood is not favoured by gravity. The contractile power of the veins of 
the upper and lower extremities is much greater; but in the case of the latter 
it is often much weakened by their almost continued state of distention to 
which they are exposed. 

Now the circulation through the other parts of the body also is affected, and 
that too very materially, by the influence of the gravity of the blood, but \n 
different degrees according to their situations and positions. As a general truth 
we may assert, that whenever the venous circulation is favoured by the gravity 
of the blood under ordinary circumstances, there will congestions be apt to take 
place, or to be much increased when they have already taken place, by any 
change of the accustomed position; and the reason of this is, that such veins 
have but little contractile power to aid in propelling their contents. To return 
to the subject of the cephalic circulation, is it not a fact of daily observation, 
that scarcely any one is able to continue long in a strictly horizontal position? 
the head must be somewhat raised above the level of the body, else unpleasant 
feelings come on, which not only prevent sleep, but may induce dangerous 
symptoms. It is not improbable that the less free return of the venous blood 
from the head when we lie down, may have something to do in the phenomena 
of sleep. And is it not, in part at least, this cause which keeps up the desire 
for sleep beyond the requisite period of repose; so that the longer we remain 
in bed, the longer still we wish to remain? It is not unfrequent to observe in 
elderly patients who have been, from whatever cause, long confined to bed, a 
set of nervous and cerebral symptoms supervene, and these may resist every 
means of rthef which may be devised. The perceptive and intellectual facul- 
ties become dull and inactive; a state of torpor and apathy, of greater or less 
degree in different cases, comes on; the patient is unwilhngto be troubled with 
anything, as the answering of questions, and so forth; and when he does return 
an answer, perhaps it is confused and rambling. These are alarming symptomsj, 
and if they continue and become aggravated we can have no hope of saving our 
patient. 

On dissection of such cases we usually discover some degree of encephalic 
congestion, and perhaps a trifling effusion within the ventricles. We deem it 
not improbable that the true source and origin of most of the mischief are to be 
sought for in the altered state of the cephalic circulation in consequence of the 
more frequent and longer continued decubitus or position in the horizontal at- 
titude. As it is with the head, so it is with other parts of the body, when they 
are kept for a length of time in a depending posture. In the chest the stasis of 
the blood is always more considerable in those parts of the respiratory organs which 
are lowest; and it has often been remarked, that pneumonia, especially when it at- 
tacks those who have been long bed-ridden, very generally affects the base of 
the lungs. Perhaps some curious and interesting results might be obtained by 
endeavouring to ascertain the comparative frequency of pneumonia on the left 
and on the right side, of engorgements of the liver, and of the spleen, in re- 
lation to the ordinary position of the patients during their sleep. It is quite 
possible that the blood may acquire a tendency to accumulation in particular 
organs on that side which the person usually assumes while asleep. 

In our July number, of last year, there is an interesting memoir of M-Piorry, 
on what he designated *' pneumonia hypostatica," or pneumonia arising from a 
continued state of congestion of certain parts of the lungs, kept up by long 
confinement in bed. Almost all the cases occurred in old infirm patients, ad- 
mitted into the La Salpetriere as objects of charity. The mere confinement 
to bed appeared often to bring on cough and other pectoral symptoms, and 
these were found to be quite irremediable, if the patients were kept all day in 
the horizontal position. 



202 QUARTERLY PERISCOPE. 

Auscultation readily discovered the seat of the pulmonary lesion; the dull- 
ness on percussion, and the absence of the respiratory murmur, with the con- 
secutive rales, heard on each side of the spine, showed that it was the poste- 
rior part of the lung's which were chiefly affected; and the post-mortem exami- 
nation confirmed in every case the accuracy of the diagnosis. — [Ed.] 

The injurious effects of a depending" position are well illustrated in the case 
of the female mamma, when not properly supported, especially during lacta- 
tion; the veins become much enlarged and distended, and not unfrequently se- 
vere darting pains are felt through the organ, giving rise to apprehensions of 
the commencement of serious disease. Then, too, the very common malady 
of haemorrhoids is another striking example of the influence of gravity on the 
circulation of the blood; and the phenomena of many uterine affections also 
afford testimony to its operation: thus numerous cases of inflammation of the 
womb are induced by the patients too soon leaving bed, and getting up; the 
change from the horizontal to the vertical position favours the more easy flow 
of blood along the uterine arteries, while it retards the returning current in the 
veins: hence, therefore, we may readily explain the occurrence of inflamma- 
tion or haemorrhage under such circumstances. Every obstetrical physician 
knows that it is of paramount importance to enjoin a reclining posture in all affec- 
tions of the female internal organs of generation. 

Again; it is the agency of mere gravity which induces a varicose state of the 
spermatic veins in men, constituting the diseases of varicocele and cirsocele, 
and these diseases are invariably aggravated by all causes which are capable of 
increasing the force of the gravity of the blood, or of relaxing the coats of the 
blood-vessels, such as exercise, long standing, heat, &c. The use of a well- 
made and well-applied suspensory affords by far the most effectual relief. But 
the phenomena which result from the influence of gravity are still more ap- 
parent and striking in the extremities of the body. If the hand has been long 
hanging by the side, especially when it is warm at the same time, the veins be- 
come full and distended, every minute ramification can be traced, and the 
whole volume of the soft parts is greatly increased, so that even a feeling of 
xmpleasant tension may be induced: by merely raising the hand and arm, and 
keeping it for some time in that position, all these appearances vanish, and the 
member resumes its wonted condition. This affords one of the best examples 
of the influence of mere gravity on sanguineous accumulations; and we can 
readily believe that the upper extremities would very often exhibit the effects 
of such accumulations, were it not for the free and frequent movements of them 
in all directions: — In the case of tlie lower limbs, the m.ovements are much 
more limited, and their position is almost always unfavourable, except during 
sleep, to the return of the venous blood; whether we are walking, standing, 
or sitting, the blood has to rise from the feet upwards against the force of its 
gravity. Hence it is that the varicose distentions of the veins of the foot, leg, 
and thigh are so frequent, and especially whenever there is any superadded 
cause, which may impede the easy reflux of the circulating fluid — the pressure 
of the gravid uterus, of an enlarged ovary, &c. is well known to be a common 
cause of such a malady. When the larger veins of the extremity have been 
varicose for some time, and especially if the patient neglects the proper means 
of rehef, the capillary veins become gradually distended and engorged — the 
surrounding cellular substance becomes inflamed, hardened, and ecchymosed, 
in consequence of blood oozing out occasionally from the over-distended ves- 
sels, and being infiltrated into the cellular parenchyma. It is under these cir- 
cumstances that the skin not unfrequently gives way, and ulcers, most painful 
and difficult to heal, become formed. Having thus briefly glanced at some of 
the most illustrative examples of the influence of gravity, as a cause of incon- 
venience and disease, we shall now direct the attention of our readers, for a few 
moments, to certain maladies in which the influence of this agent is conspicu- 
ously observed. 
In severe cephalic neuralgias, the horizontal position is often found to aug- 



Physiology. 203 

ment the sufferings of the patient; and the only attitude in which he can find 
any rest, is with his head well elevated. We do not mean to imply that these 
cases are of an inflammatory nature, yet it is very evident that they are much 
afferavated by any sanguineous congestion in the parts affected. In phrenitis, 
otitis, erysipelas of the face, the higher the head is kept raised, the more rehef 
the patient experiences; and when any local inflammation, as of one ear, ex- 
ists, we uniformly observe that the symptoms are mitigated by lying on the op- 
posite side. Ophthalmia has often been translated from one eye to the other, 
by the person continuing to lie on the sound side when the inflammation was 
abating in the other, and this alternation of the seat of the disease may be re- 
peated several times, if the physician's attention be not directed to the real 
cause. The spreading of erysipelas on the trunk appears to be not unfre- 
quently influenced by the position of the patient; the tendency to spread is ge- 
nerally in a direction to the most depending parts — those on which the patient 
is resting; and rarely upwards, or to a part more elevated than the spot from 
which it has started. We have already alluded to the frequency of pneumonic 
attacks of the lower and back parts of the lungs, in patients who have been 
long bed-ridden, from whatever cause; and it is unnecessary to do more than 
merely again to point to diseases of the rectum, uterus, and male organs of 
generation, in proof of the influence of position. In the treatment of ulcers 
of the leg, we are firmly of opinion that repose of the limb, in the horizontal 
posture, is by far the most important of all therapeutic means; poulticesj lotions, 
and ointments will often all fail, unless this necessary adjunct be attended to at 
the same time; and even when the patient is not strictly confined, do we not inva- 
riably employ what may be called compensating remedies, viz. strips of adhesive 
piaster, or rollers from the toes up the vi^hole length of the limb? and the eflect 
of these is well known to be, the taking off the pressure of the superincum- 
bent column of blood from the veins of the foot and leg. 

M. Gerdy, about a twelvemonth ago, instituted a number of experiments at 
the HdpitalSt. Louis, on the different methods of treating ulcers; different sets 
of patients were submitted to the different methods, and each method was em- 
ployed by itself, in order that the results of each might be justly appreciated. 
Many of the details have been published in the article *' Attitude," in the Nou- 
veau Dictionnaire de Medecine. We shall mention a few of them. 

When the limb on which an ulcer existed was kept upon an ascending in- 
clined plane, it was found that the sore became pale, the suppuration was di- 
minished in quantity, and a crust soon began to be formed upon the surface, 
and under this the healing went on more or less rapidly. If strips of adhesive 
plaster were used, at the same time that the elevated inclined position was re- 
tained, the cure was still more rapid: it was by combining the elevation with 
the use of adhesive bandages, and the entire repose of the limb, that cicatrization 
of the ulcer was most speedily effected. Several cases of severe contusion 
were treated on the same plan, with very decided success — the contused limbs 
being retained in an elevated inclined position during the whole period of the 
treatment; the decrease of the pain, tension, and tumefaction was sometimes 
truly remarkable. 

M. Gerdy is of opinion, that many white swellings of the joints may be very 
materially benefited by an application of the principles which have directed 
his treatment of ulcers. He recommends that the affected limb be kept per- 
fectly quiet, and on an inclined plane, so that the foot is considerably more ele- 
vated than the thigh. He is not yet provided with the reports of any cases to 
prove the correctness of his ideas; but in one case of elephantiasis of the leg, 
treated by elevation of the limb, and compression at the same time, the result 
was most satisfactory — the subsidence of the enlargement was very striking. — 
Med. Chir. Mev. & Jlrckiv. Generaks, Dec. 1833. 

12. Of the Chemical Properties of the Secretions in Health and Disease, and of 
the existence of Electrical Currents determined in Organized Bodies by the Acidity 
and Alkalinity of the Membranes. By M. Donue.— 1. From the whole surface of 



204 QUARTERLY PERISCOPE. 

the skin is secreted an acid humour. The sweat, however, instead of being, 
as is generally said, very acid under the arm-pits, and round the g-enital organs, 
is, on the contrary, as alkaline in these parts as at the toes. 

2. The digestive canal from the mouth to the anus secretes an alkaline mu- 
cus, except in the stomach, where the gastric juice is very acid. Thus the 
saliva and the mucus of the cesophagus, as far as the cardia, are alkaline in a 
healthy state, and become acid only in consequence of disease. From the 
pylorus to the end of the intestinal canal, the mucus furnished by the mucous 
membrane itself is alkaline. 

3. Serous and synovial membranes all secrete an alkaline liquor in a normal 
state, which in certain diseases sometimes becomes acid. 

4. The external acid and the internal alkahne membranes of the human 
body represent the two poles of a pile, the electrical effects of which are ap- 
preciable by the galvanometer. Thus, in placing one of the conductors of the 
instrument in contact with the mucous membrane of the mouth, and the other 
in contact with the skin, the magnetic needle deviates fifteen, twenty, and 
even thirty degrees, according to the sensibility of the galvanometer, and its 
direction indicates that the mucous or alkaline membrane takes negative elec- 
tricity; and the cutaneous membrane positive electricity. 

Independently of these two great surfaces presenting opposite chemical 
states, there exist other organs, the one class of which may be called acid, and 
the other alkaline, and which produce the same result; between the stomach, 
for instance, and the liver of all animals, extremely powerful electrical cur- 
rents are found. 

5. M. Donne has observed electrical phenomena of the same kind in vegeta- 
bles, of which he gives examples, but electrical currents in vegetables are not 
produced by the acid or alkaline states of the parts as in animals, because the 
juice of fruits, at least such as M. Donne examined, is throughout more or less 
acid. Accordingly, however, to the beautiful experiments of M. Biot, the 
juices which arrive by the pedicle are modified on some part of the fruit, and 
it is perhaps to this difference of the chemical composition of the juices of the 
two extremities that the electrical phenomena are to be attributed. 

6. The acid humours of the economy may become alkaline, and vice versa. 

7. Acidity is usually the result of inflammation, properly speaking, which 
may be produced by sympathy in an organ situated at a distance from the in- 
flamed point. Thus the saliva becomes very acid in inflammation of the 
stomach. 

8. The acid which is developed in inflammation appears to be most fre- 
quently the hydrochloric. The presence of this acid produces coagulation of 
the albuminous part of the lymph, or of the serosity which abounds in inflamed 
parts. The false membranes in the serous cavities, the albuginous spots of the 
eye, the coagulable lymph of wounds, the thickenings of certain organs, and 
many other morbid productions resulting from inflammation, in which there is 
found by analysis only albumen, more or less coagulated, are owing to this. 

Pus itself is produced by the action of the acid on albuminous lymph. It is 
a kind of union of the acid with the albumen. If free acid be not found in the 
liquids effused on the surface of inflamed organs, it is owing to the humours of 
the body being very alkahne, and containing sufficient potass and soda to neu- 
tralize the acid. In the memoir, however, of which this paper is a summary, 
M. Donne has cited many cases in which pus and even the serum effused into 
the abdomen in consequence o^ peritonitis were found acid. An analogous case 
was reported to M. Donne by M. Dumas, and another is mentioned by Berzelius 
in his treatise on chemistry. 

9. The changes in the chemical nature of the secretions react on the differ- 
ent systems of the economy, forming an interesting order of lesions and symp- 
toms in connexion with the etiology, the diagnosis, and even the treatment of 
diseases. These changes according to M. Donne, produce modifications of the 
electrical currents which exist between the different organs of the economy. — 
Ed> Med. & Surg. Journ. and Journ, Hehdom. Feb. 1834. 



Pathology, 205 

13. Adion of Sugar upon Human Blood. — Professor FIegewisch, of Keil, 
states that a solution of sugar produces the same alteration in the colour of 
black blood as the saline solutions, namely, changing' it to a bright arterial co- 
lour. — Gazette Medicale de Faris, April lith^ 1834, 



PATHOLOGY. 

14. Foreign Body found in the Heart of a Boy. — The following very curious in- 
stance of this is recorded by T. Davis, Esq. of Upton upon Severn, in the second 
volume of the Transactions of the Provincial Medical and Surgical Association. 

** On Saturday evening, January the 19th, 1833, I was summoned to attend 
Wm. Mills, aged ten, living at Boughton, two miles from Upton. When I ar- 
rived, his parents informed me that their son had shot himself, with a gun made 
out of the handle of a telescope toasting-fork. To form the breach of the gun, 
he had driven a plug of wood about three inches in length into the handle of 
the fork. The touch-hole of the gun was made after the charge of powder had 
been deposited in the hollow part of the handle. The consequence was, that 
when the gunpowder exploded, it forced the artificial breach, or piece of 
stick, from the barrel part of the gun with such violence that it entered the tho- 
rax of the boy, on the right side, between the third and fourth ribs, and dis- 
appeared. Immediately after the accident, the boy walked home, a distance 
of about forty yards. 

** By the time I saw him, he had lost a considerable quantity of blood, and 
appeared very faint; when I turned him on his right side, a stream of venous 
blood issued from the orifice through which the stick entered the thorax. Se- 
veral hours elapsed before any degree of reaction took place. He complained 
of no pain. 

" For the first ten days or a fortnight after the accident, he appeared to be 
recovering, and once during that time walked into his garden and back, a dis- 
tance of about eighty yards; and whilst there he amused himself with his flow- 
ers, and even stirred the mould. He always said he was well, and was often 
cheerful, and even merry. There was no peculiar expression of countenance, 
excepting that his eyes were rather too bright. 

"After the first fortnight he visibly emaciated, and had frequent rigors, 
which were always followed by faintness. The pulse was very quick. There 
was no cough nor spitting of blood. The secretions were healthy. He had 
no pain throughout his illness. 

" He died on the 25th of February, five weeks and two days after the oc- 
currence of the accident. 

^* Dissection. — On opening the thorax, a small cicatrix was visible between 
the cartilages of the third and fouth ribs, on the right side, about half an inch 
from the sternum. 

"The lungs appeared healthy, with the exception of a small tubercle at the 
right, and at its root, near to the pulmonary artery, a small blue mark in the cel- 
lular tissue, corresponding in size with the cicatrix on the parietes of the chest. 

•* Half an ounce of serum was contained in the pericarduim. 

*' When an incision was made into the heart, so as to expose the right auri- 
cle and ventricle, we were astonished to find, lodged in that ventricle, the 
stick which the boy had used as the breach of the gun, the one end of it press- 
ing against the extreme part of the ventricle, near the apex of the heart, and 
forcing itself between the columnae carneas and the internal surface of the heart; 
the other end resting upon the auriculo-ventricular valve, and tearing part of 
its delicate structure, and being itself encrusted with a thick coagulumas large 
as a walnut. 

** We searched in vain for any wound, either in the heart itself or in the peri- 
cardium, by which the stick could have found its way into the ventricle." 

No. XXIX. —November, 1834. 18 



206 QUARTERLY PERISCOPE. 

15. Cases illuslraUngthe Terminations of Ovaritis Puerperalis.— The epithet 
puerperal, applied to this affection, is not to be considered as indicating- that it 
occurs only after delivery. In the 4th vol. of the "Clinique des H6pitaux,"is 
a report of the dissection of a woman, (who never had been pregnant,) in 
whom the right ovary was found inflamed and much enlarged, from a purulent 
deposit, of a most fetid character. In another case, occurring under similar 
circumstances, the pus made its escape by the rectum, and the patient recovered. 

In many of its features, ovaritis bears a strong resemblance to the abscess of 
the iliac fossa, the history of vi'hich has been so ably illustrated by Dupuytren, 
Dance, and others. At present, we shall confine our observations to the mere 
furnishing of cases, descriptive of the different modes in which ovaritis may 
terminate. 

1. By Resolution. A woman, thirty-three years of age, was admitted into the 
Hotel-Uieu on the fifteenth day after defivery. The labour had been painful, and 
the child extracted by turning. The symptoms were oedema of the abdominal pa- 
rietes and of the inferior extremities, suppression of the lochia, a swelling in 
the left iliac region, painful on touch; strangury; whitish, creamy deposite in 
the urine, and sense of weight in the vagina. By active local bleeding, and ap- 
propriate constitutional treatment, this woman speedily recovered. 

2. By Suppuration,. This is a very frequent termination. The pus makes 
its escape either, a, by the rectum, as in the following case. 

A young woman presented a general emaciation — slight effusion into the ca- 
vity of the abdomen, enlargement of the liver, a swelling as large as a hen's 
^^^t in the left iliac region, painful on pressure — amenorrhcea — urine contain- 
ing a whitish substance, which appeared like pus; well-formed pus mixed with 
the stools; body and neck of the uterus healthy to the touch, by which it was 
discovered that the tumour in the groin was connected with the womb and 
bladder. The patient was generally feverish, and more so towards evening. 
Numerous leeches were applied to the swelling, and hot fomentations after- 
wards. The progress of the case is not known, as she left the hospital unex- 
pectedly. It ought, however, to be stated, that she had been delivered of a 
seven-month child three years before her admission, after a severe, but rapid 
labour. Three months after this date, she began to experience pains in the 
liypogastrium and groins, and these had continued with more or less severity 
ever since. In such cases of purulent diarrhoea, the pus may make its way 
either into the coecum, the arches of the colon, or into the rectum. In the fol- 
lowing case, it seems to have escaped into the left arch of the colon. 

A woman was seized, on the second day after delivery, with all the symp- 
toms of peritonitis; on recovering from which, she had an attack of phlegmasia 
dolens. While under treatment for this, a painful tumour made its appearance 
in the left groin. This attack of ovaritis was no sooner over, than she was 
again seized with peritonitis, in consequence of imprudently walking on a cold 
stone floor. On the 22d of March, (seven weeks after her admission into the 
hospital,) the left limb was still oedematous; and on this day was first observed 
purulent matter mixed with the alvine evacuations. The great relief which the 
patient almost instantaneously experienced m the inguinal swelling-, on the oc- 
currence of this purulent discharge, could leave no doubt but that it proceed- 
ed from the ovary, which had very probably become adherent to the sigmoid 
flexure of the colon. During a space of two months the discharge ceased, and 
returned several times; and even when the patient left the hospital, on the 23d 
of June following, there still remained a degree of engorgement in the left 
groin, and slight oedema of the limb. 

h. The pus may find an exit by the bladder or vagina. MM. Husson and 
Dance found that this had taken place in a young girl who died of the 
disease. 

c. It may follow the course of the round ligament, and escape at the inguinal 
or crural apertures. Dupuytren has seen numerous cases of such a termina- 
tion. Under these circumstances, the tumour may be mistaken for an aneurism, 



Pathology. 207 

as it frequently pulsates, from being in close proximity to the iliac artery. In 
opening- abscesses at this point it is necessary to use considerable caution, as in- 
stances have been known where the artery has been inadvertently wounded. 

d. It may pass into the abdominal caviiy, and either become encysted, or in- 
duce fatal peritonitis: and, e, lastly, it may be discharged at some point of the 
hypogastric or ihac regions, (besides the inguinal aperture,) in consequence of 
the ovary becoming adherent to the abdominal parietes, and the matter gradu- 
ally working its way out. This termination is illustrated by the following case. 

A woman, twenty-four years of age, was delivered of her sixth child on the 
17th Nov. The labour was rather painful and difficult. Imprudent exposure 
to cold was quickly succeeded by an attack of fever, by suppression of the 
lochia, and a tumefaction of the right groin. When received into the hospital, 
the tumour was of the size of an ^^^^ and the limb was adematous. 

In spite of repeated leechings, &c. the suppurative process commenced, and, 
by the end of January, several fistulous openings through the abdominal walls 
had taken place; and from these a copious discharge of pus flowed out. The 
patient gradually regained her health, and left the hospital, quite cured, a few 
weeks afterwards. 

In the 4th vol. of the Bibliotheque Medicale is narrated in the case of a lady, 
in whom two iliac abscesses, supervening upon an attack of entero-peritonitis, 
opened, the one into the sigmoid flexure of the colon, the other into the coecum 
— and this last also projected outwardly. An incision was unfortunately made 
into it, and a stercoral fistula was the consequence. 

3. By Ramollissement. The ovary becomes tumefied, infiltrated with a sero- 
purulent fluid, and either friable and easily lacerated, or extremely soft and 
yielding in texture. Dr. Montault saw an example of this degeneration in a 
young girl, who died of puerperal peritonitis. The labour had been quite na- 
tural and easy, but she had suflTered much from mental anxiety, and had been 
exposed to cold, when she was brought to the hospital after delivery. 

4. By Enlargement mid Induration. A young woman was seized with metro- 
peritonitis, five days after her discharge from the Maternite, where she had 
been safely delivered. She died on the sixth day of the disease, having, on the 
day or two preceding her dissolution, exhibited all the symptoms of ataxic fever, 
(from the absorption of purulent matter into the system.) On dissection, a 
small quantity of pus was found infiltrated into the superior and lateral por- 
tions of the uterus. The right ovary was more enlarged than the left, hardened 
in texture, and of a yellowish colour; firm pressure forced out only a few drops 
of pus. This state of induration will often continue for a long period without 
affecting the general health; although it must be confessed that, not unfre- 
quently, the patient is annoyed with colicky pains, proceeding from the site of 
the ovary, with dysmenorrhoea and other troublesome symptoms. 

When these are exceedingly obstinate, and progressively become more dis- 
tressing, we may suspect that the enlarged and hardened viscus is degenerating 
into scirrhous, lardaceous, osseous, melanotic, or hydatidic condition. — Med. 
Chir. Rev. & Journ. Hehdom. 

16. Fatal Case of Effusion of Blood into the Pericardium. By Dr. Caksost, of 
Liverpool. — Mr. W., a gentleman about fifty-two years of age, of a tall and ro- 
bust form, clear complexion, subject occasionally to dyspeptic affections; though 
of very regular and temperate habits; of an active disposition, though his oc- 
cupation was sedentary and confining; had been for twelve months affected with 
considerable anxiety of mind, in consequence of the doubtful issue of some 
building speculations. Towards the end of Lent, which he had rigidly observ- 
ed according to the injunctions of the Catholic Church, on the 11th of March, 
a day exempted from the prohibitions respecting diet, he had eaten freely of 
beef-steaks with onion sauce. He was at that meal sparing as usual in the use 
of wine. On the evening of the following day, be was engaged in a fatiguing 
and rather anxious way with the business of a club, of which he was treasurer. 



208 QUARTERLY PERISCOPE. 

On his return from the club, about eleven o'clock at nig-ht, in company with 
two of his friends, when he had nearly reached his own house, he was seized 
with faintness and debility to such a degree, that without the assistance of the 
friends who accompanied him he would not have been able to have kept his 
feet. Soon after his arrival at his house, he was visited by Mr. Bromilow, his 
medical attendant. He described himself as faint and exhausted; complained 
of an obtuse, heavy pain at the precordia, and was affected with flatulent eruc- 
tations. His respiration was free, his pulse 70, and regular, though weak. He 
had no affection of the head, nor pain any where, excepting as described in the 
chest. His bowels had been opened that day. Mr, Bromilow ordered an anti- 
spasmodic draught; and left him with directions to take something warm, and 
go to bed. He took the draught, and a weak glass of brandy and water. At 
three o'clock he sent for Mr. B, again, and, as the pain in the chest was not 
abated, he expressed a wish to be bled, which Mr. B. agreed to, more with the 
hope of satisfying his mind than from any great necessity for that measure be- 
ing indicated by the symptoms. He lost a pint of blood. An opiate was then 
administered. At this visit Mr. B. examined the chest more minutely. He ap- 
plied his ear to the different regions of the naked chest, but perceiving no un- 
sual sound or vibrations, concluded that the heart, lungs, and large vessels 
were in a sound state. At five o'clock. A. M. I visited him. He felt cold, per- 
spired gently, and chiefly complained of a pain in the chest, which he described 
as wearisome and oppressive. It was not increased by taking a full inspiration. 
He had vomited a little in the course of the night, and had discharged some of 
the onion sauce he had taken the day preceding the attack. He was much 
troubled with flatulency, and belched frequently, but was not relieved by it so 
far as regarded the pain in the chest. His pulse was regular; the heat of the 
body natural; and respiration good. He had had no sleep. 

From the information given by Mr. Bromilow, connected with my own ob- 
servation, I considered that nothing could be indicated by the symptoms be- 
yond an aflfection of the stomach, which is known to exhibit itself in such ano- 
malous forms. He took four grains of calomel, and two of opium. We visited 
him again at half after eleven o'clock. He had had little sleep. The symp- 
toms remained the same. He was ordered an aperient mixture, and we pro- 
posed to visit him again at seven o'clock. At this visit, I replied to the anxious 
inquiries of the family — that we did not see any cause for alarm; that the com- 
plaint seemed to arise from indigestion; and that I had no doubt he would re- 
cover. At three o'clock in the afternoon he sent for Mr. Bromilow, as the pain 
still continued unabated, and wished to know if he might have any thing to 
rub the part with. The bowels had not been opened, and he had had little or no 
sleep. A short time before seven o'clock, the hour at which we had proposed 
to visit him, and at which I was prevented from attendance by an urgent call 
to a distant part of the country, Mr. W. was seized with what the family con- 
ceived to be a fit; and a short time after the arrival of Mr. Bromilow, expired. 
In consequence of my unavoidable absence, other physicians were called in, 
and two arrived, but not until after the death of the patient. I applied for per- 
mission to open the body, which was granted. The body was examined twenty- 
four hours after death, by Mr. Bromilow, in my presence, and in that of my 
son, Dr. Carson, Jr. The following were the appearances on dissection. Upon 
opening the chest, the lungs on both side were perfectly sound and collapsed. 
But, notwithstanding the collapse, the chest was filled more than it usually is 
when the lungs are sound. This indicated the existence of some foreign sub- 
stance, or morbid enlargement of some of the organs. The pericardium was 
found accordingly to be immensely distended by some fluid, which, when this 
bag was opened, was found to be blood, partly liquid and partly coagulated: 
the quantity was not less than three pints. It was purely blood, without the ad- 
mixture of any fluid indicating inflammatory action. The external surface of 
the heart, and internal surface of the pericardium were examined carefully, but 
no ruptured vessels, from which the blood might have flowed were discovera- 



Pathology, 209 

ble on either of these surfaces. The heart itself was perfectly sound, the valves 
were in g-ood condition, and no disease existed in any of the large vessels. The 
lungs were free from adhesions, and were every where sound. The other vis- 
cera were in a sound state. A great deal of care and time were expended in 
tiying to discover the source from which the blood had flowed into the pericar- 
dium, but in vain: a slight ecchymosis was observed about the root of the pul- 
monary artery. Dr. Baillie, in his Morbid Anatomy, says, '* Cases have occurred, 
though very rarely, in which a large quantity of blood has been accumulated 
in the cavity of the pericardium, but where no rupture could be discovered 
after the most diligent search, either in the heart itself, or in any of its ves- 
sels. This appears very wonderful, and not at all what any person would ex- 
pect a priori. Two conjectures have occurred to me, to explain this pheno- 
menon: 1st, that the blood-vessels on the surface of the heart have lost their 
compactness of tissue, so that the blood may have escaped by transudation. 
The other is, that the blood may have been poured out by the extremities of 
the small vessels opening on the surface of that part chiefly of the pericardium 
forming the immediate cover of the heart, from their orifices having been to a 
very uncommon degree relaxed." 

There is a case related by Dr. Alston, in the 6th volume of the Edinburgh 
Medical Essays, in which the disease of the chest was of long standing. Three 
pints of blood, which was partly coagulated and partly mixed with lymph, 
were found in the pericardium. No ruptured vessel was discovered either on 
the outer surface of the heart, or the inner surface of the pericardium. Upon 
pressing the heart, a bloody serum oozed out of a great many orifices on its 
surface, and principally near its base. No disease was discovered in the interior 
of the heart or large vessels. Dr. Baillie refers to two cases of extravasation 
of blood into the cavity of the pericardium, in which the source of the lijemor- 
rhage could not, after the most careful examination, be discovered. In both 
these, functional disease of the heart had been observed for some time previous 
to the death of the patient. Vide Medical Observer, vol. 10, p. 330. Memoirs 
of Medical Society, vol. 1, p. 238. 

Various opinions have been advanced respecting the sources from which, in 
the above cases, the blood was derived. One of the suppositions made by Dr. 
Baillie appears to me to approach the nearest to the truth, which is that the 
blood had oozed out of the small vessels on the internal surface of the pericar- 
dium immediately covering the heart. It is probable, I think, that the oozing, 
particularly in the case now narrated, arose from the condition of the blood, and 
the relaxed state of the fibres. It would appear that the disease was general, 
and that the shivering, faintness, and depression of spirits were not the effects 
of the flow of blood into the pericardium, but that this last was, like the affec- 
tions stated, the effect or symptom of the general disease — that in fact there 
existed a morbid state of the whole system, similar to that which takes place 
in purpura, in some kinds of epistaxis, haematemesis, and bleeding from the 
bowels in typhus fever. The pain in the chest was in the first place occasioned 
by the admission of blood into a cavity not accustomed to the stimulus of that 
fluid. There is no reason to suppose that the action of the heart would be 
mechanically affected until the quantity of the blood was pretty considerable; 
for the blood would readily follow the dilatation of the pericardium occasioned 
by the elasticity of the lungs when the chambers of the heart had finished their 
contractions. No sound was perceived on carefully examining the chest. In- 
deed no sound could be excited, as no fluid was poured from one vessel into 
another. For as the auricles expand as the ventricles contract, the change of 
place in the constituents of the fluid in the pericardium would be inconsidera- 
ble, and made with quietness. 

There does not appear to be any symptom in this case that would have war- 
ranted the medical attendants in giving an unfavourable prognosis. As a mat- 
ter of prudence, a less favourable one might have been made, but the same 

18* 



210 QUARTERLY PERISCOPE. 

prudence would not permit the expression of a favourable prognosis in any case 
whatever. — Liverpool Medical Journal, No. I. 

17. Extensive Mesenteric Disease — Great Heat of the Whole Body the Chief 
Symptom. — Giovanni L. set. 36, a countryman, was admitted into the hospital at 
Padua in February, 1830. His only complaint was a burning- heat over every 
part of his body; and this was so distressing, that, although the weather was 
exceedingly cold, he lay all night without any coverings. Two bleedings from 
the arm, and cooling purgatives, relieved him so much that he was able to re- 
turn home. In the month of May he returned, labouring under the same dis- 
tress, and was again made well by a similar treatment. At this time, however, 
some symptoms of a hypochondriacal affection were first observed. 

A fortnight after his second dismissal he came back, in consequence of a 
mild attack of continued fever, accompanied with that feeling of burning heat 
which had so much distressed him before. A variety of remedies were tried, but 
with few good effects, the fever continuing in spite of them, and the patient 
gradually losing strength and flesh. The pulse being firm and hard, he was 
bled from the arm, and twelve leeches were applied round the anus. Being 
considerably relieved by this treatment, he was induced to leave the hospital. 
He was not, however, long absent, and on his return his condition was decid- 
edly worse. The pyrexia! symptoms were much aggravated, but he no longer 
complained of the burning heat; his emaciation was much greater. 

Repeated examinations of all the great cavities of the body were made by 
more than one experienced physician, for the purpose of ascertaining, if pos- 
sible, the seat or exciting cause of the prolonged duration of fever; but no 
very satisfactory conclusions could be arrived at by any one. It was suspected, 
however, that the "fons et origo mali" was probably seated in the lower part 
of the abdomen. 

A diarrhoea came on, and, as it could not be checked, the patient speedily 
sunk under its effects. He died about the middle of August. 

Autopsy. — When the abdominal cavity was laid open, and the small intes- 
tines, which were found contracted and quite empty, had been pushed up, an 
extraordinary mass of indurated disorganized glands presented itself to view. 
It was fully as large as two fists put together, and, when divided, exhibited a 
yellow colour, and a structure not unlike to that of genuine scirrhus. So ge- 
neral was the morbid change, that not one healthy gland was discovered in the 
whole course of the mesentery. It was very naturally a subject of great surprise 
how such an enormous enlargement as existed at one part could have escaped 
detection during life, seeing that the abdomen had been repeatedly examined 
with great care. The only way in which we can explain this, is by supposing 
that the intestines were always interposed between the mass and the parietes 
of the abdomen. 

Remarks. — The preceding case is very interesting in several points of view; 
and of these not the least important is that of illustrating what extensive dis- 
organization may be going on in certain viscera, and yet the symptoms, espe- 
cially the local ones, may be very obscure and unsteady. The leading feature 
in our patient was the extreme heat and sense of burning which he felt in every 
part of his body. 

It may, therefore, be worthy of the attention of physicians whether this symp- 
tom is not more frequently attendant upon mesenteric disease than has been 
hitherto noticed. We have certainly observed it, more than once, in some of 
the abdominal affections of children. — Med. Chir. Rev. andAnnali Univers. di 
Med. 

18. Case of Paraplegia — Suppression of the Urinary and Anal Evacuations 
during Eleven Years. — When Dr. Montesanto first saw this patient in April, 
1831, he had been paraplectic for upwards of eleven years, and was suffering at 
the time from the sequelse of a severe attack of pneumonia; so that it was not 



Pathology. 211 

expected that he could lon^ survive. The thoracic symptoms, however, gra- 
dually disappeared, and he was then in the same paralytic condition in which 
he had remained since the year 1820. His appetite was vigorous; but the food 
seemed to meet with some obstruction, probably at the pylorus, for it was re- 
gularly rejected by vomiting in about three hours after it had been swallowed. 
It is stated that at a former part of his illness a stercoraceous vomiting, which 
had previously recurred at intervals of from forty to fifty days, had ceased alto- 
gether for more than two years. No secretion of urine nor evacuation peranum 
had taken place since the commencement of the disease, in 1820; neither dur- 
ing all these years had there been any trace of activity in the generative or- 
gans. Strange that with such a defect and morbid state of the alimentary and 
urinary organs, the general health of the patient should have continued moder- 
ately good. Towards the close of the year 1831 he had a threatening of the 
return of his thoracic complaints; but they were speedily removed by appro- 
priate treatment. Occasionally, too, when he eat any food which disagreed 
with his stomach, or took it at improper times, he was seized with alarming 
symptoms of cramp and inefTectual efforts at vomiting. One of these attacks, 
which had been brought on by a repast of fried sardinias, nearly proved fatal 
in the spring of 1832; for fifteen days his life was despaired of; fortunately then 
a spontaneous vomiting occurred by which he rejected four large masses of so- 
lid stercoraceous substance, which seemed to have been impacted in the intes- 
tines. Nature having thus relieved herself of an immense accumulation of faecal 
matter, which had been gradually collecting for a space of nearly three years, 
the health of the patient was speedily restored to its former condition. It was 
necessary every now and then to take away a small quantity of blood by vene- 
section, to counteract in some degree the stimulating and plethoric effects of 
the ardent spirits which the patient was in the habit of drinking. 

In the summer of the following year Dr. Montesanto makes the report, "that 
his patient's health for the last twelvemonth has been on the whole exceedingly 
good; and that there has been no return of the stercoraceous vomiting during 
that period." 

The paralytic state of the lower half of the body remained unchanged; all 
sensibility quite gone, but the limbs not wasted, and though motionless at will, 
were supple and flexible. 

The authentic particulars now related have attracted the attention of many 
of the most distinguished physiologists and surgeons in Europe; the case 
altogether is one of the most wonderful on record — the mode of existence in 
this man being allied to the normal condition of life in some of the lower 
classes of animals. — Ibid^ August, 1833. 

19. Case of Apparent Death \_Life?'\ which lasted Three Weeks. — A young man 
who had recently been cured of a tertain fever, was admitted into the hospital 
at Paderborn, under the care of Dr. Schmid, for symptoms indicating tubercu- 
lar phthisis. He gradually became exceedingly emaciated, and at length died. 

After all traces of breathing had ceased, a few irregular beats of the pulse 
were felt, and the eyes opened of themselves. Some small eschars artificially 
produced, exhibited signs of suppuration on the second, third, and fourth days. 
On the fifth, one hand was found to have been turned round; and on the sixth 
and ninth days a partial perspiration bedewed the skin. After this period se- 
veral pemphigus-like bullse made their appearance. The limbs remained quite 
pliant; the lips preserved their red colour until the eighteenth day, and the ex- 
pression of the features even at this date was that rather of a living than of a 
dead person. At the end of the third week there was no offensive smell nor 
any other sign of putrefaction.— ilfed Chir, Rev. and Journ. der Prad. Heil- 
kunde. 

20. Cyst in the Brain. — M. Verkois has presented to the Anatomical Society 
of Paris, a cyst of the size of a large nut, which he discovered in the posterior 



212 QUARTERLY PERISCOPE. 

part of the right hemisphere of a patient who had died of laryngeal phthisis, 
and who had never exhibited any symptom of disease of the brain. — Archives 
Gen. March, 1834. 

21. Acute Rheumatism terminating in Suppuration. — The termination of rheu- 
matism by suppuration is certainly not common, though MM. Guersent and 
Dakce state that they have met with a considerable number of cases of it, the 
former in children, and the second in women in child-bed; M. Louis has also 
met with one example of it, an account of which is pubhshed in the Gazette 
Midicale for 1831. A still more striking case is related by Dr. Degardin in the 
journal just named for April 12th, 1834. 

22. On Cancer of the Stomach. By William Stokes, M. D. — [Extracted from 
his Lectures on the Theory and Practice of Medicine, delivered at the Medical 
School, Park Street.] Pathologists are divided as to what is the cause of cancer 
of the stomach, but the best informed are of opinion that, in those cases of gas- 
tric disorganization, which are called cancer or scirrhus, all that can be demon- 
strated by the knife is referable to the results of chronic inflammation. This is 
a different proposition from saying, that chronic inflammation alone will produce 
cancer. As yet we know little of cancer; dissection of cancerous organs gives 
but scanty information; but this seems certain, that, in particular conditions of 
the economy, an inflammation of the stomach will end in cancerous disease. 
Here is an excellent preparation of the stomach of a person who died of cancer 
of that organ. For several years before his death he had a jaundiced look, an 
emaciated appearance, frequent vomiting, and severe pain towards the termina- 
tion of the digestive process, a circumstance which denotes disease of the py- 
lorus. He had also haematamesis. You see the inner surface in the vicinity of 
the pylorus presents ulcerations of the mucous membrane and thickening of the 
sub-mucous cellular tissue. The pylorus itself does not appear to be at all 
contracted, but the parts around it are in a state of extraordinary disease. Look 
at the preparation again, and say what could bitters, or acids, or alkalies, or 
tonics have effected in a case of such extensive disease. Here is a stomach, in 
a state of long-continued chronic inflammation, and exhibiting lesions, which 
some would designate as cancer of that organ. Now, though I do not know the 
treatment which this patient underwent, I would venture to say, that he took 
plenty of the usual anti-dyspeptic medicines. Yet in a vast number of cases, 
when enormous quantities of these remedies are taken daily, the stomach is in 
as bad a state as that preparation exhibits, and I feel the more strongly con- 
vinced of this, because I am aware that many persons die after having gone 
through the whole routine of anti-dyspeptic practice, and, when they are opened 
after death, incurable disease of the stomach is discovered. Here is an example 
of vast cancerous disease of the stomach; here is a very interesting specimen of 
chronic gastritis, chiefly representing a most remarkable and circumscribed 
ulcer at the termination of the stomach. Here you see is the ulcer, with raised, 
thickened, and introverted edges. Now, in all probability this ulceration was 
exceedingly chronic, for you perceive nature has been at work with it, and has 
made some attempts at preparation. It is in such a case as this that patients 
generally refer their pain to a particular part of the stomach: digestion goes on 
without any pain until the food reaches a certain point, when acute pain is felt, 
and this continues until it is relieved by vomiting. The occurrence of this 
symptom, after an attack of acute gastritis, would lead you to suspect the for- 
mation of one or more ulcers, and the persistence of this locahzed pain should 
induce you to persevere in employing every means in your power calculated to 
remove the disease. The preparation which I now exhibit is interesting, as it 
shows the effect of corrosive poison on the stomach. The patient, to whom this 
stomach belonged, died in consequence of swallowing a quantity of sulphuric 
acid; here you see the consequences, the mucous membrane is black and dis- 
organized, exhibiting this ragged appearance. In some cases of malignant fever 



Pathology, 213 

we have found the stomach presenting somewhat similar appearances; and the 
same state of the stomach is described by some writers as occurring in cases of 
intertropical fever. Here is a preparation, which you should inspect, chronic 
g-asiritis with a large ulcerated patch in the centre of the slomach. Here is 
another example of extensive cancerous disease. 

A very ie.\^' words will suffice for the state of the science on the subject of 
cancer of the stomach. It is very hard, nay, even almost impossible, to draw a 
line of distinction between the symptoms of cancer of the stomach and chronic 
gastritis, and I believe it is admitted on all hands that the same causes give rise 
to both. Long continued irritation will, in one case, produce cancer of the sto- 
mach, in another, chronic gastritis. Again, it is admitted by many, that what 
is called cancerous ulceration of the stomach has no appreciable difference from 
ulceration in various other organs; and hence some persons have gone so far as 
to say that there is no such thing as cancer of the stomach, (separately consi- 
dered;) and that all the cases adduced of it are nothing more than so many forms 
of chronic gastritis. In the present state of medicine, we are not, indeed, pos- 
sessed of any data which would enable us to come to a final determination on 
this question. It is certainly impossible to determine this point; but if there be 
any thing peculiar in cancerous matter, similar to tubercular or melanotic matter, 
there is no reason why, under the influence of inflammation, it should not be 
developed in the stomach, as well as in any other part of the body. But what- 
ever views we entertain on this subject, we must confess that, in the majority 
of cases, there is a chronic gastritis, and that the principles of treatment which 
would alleviate the patient's sufferings and prolong life, are those which are cal- 
culated to prevent the occurrence of gastric inflammation. The more you approxi- 
mate the treatment of cancer to that of chronic gastritis, the greater comfort 
will you afford your patient, and the more will you prolong his existence. 

The most celebrated case on record of this affection is that of the Emperor 
Napoleon. He died with extensive ulceration of the stomach, which, of course, 
was called " cancerous^" and there was also distinct traces of disease of the liver, 
the mucous coat of the intestines, and the lungs. His disease was believed by 
himself to have originated in the stomach, and to this opinion he adhered, not- 
v.'ithstanding the results of some solemn consultations, at one of which his affec- 
tion was declared to be an *' obstruction of the liver,'' with a " scorbutic discrasy.'^ 
At another it was pronounced to be a " chronic hepatitis," and a course of mer- 
cury recommended! When we reflect on this, and read in the account by 
Gaubert, (which you will see in the Examen des Doctrines Medicates,') the re- 
gimen which was used, and the list of stimulating medicaments employed, you 
will not wonder at the words of this great man, when he was pressed to take 
more drugs, to swallow the universal nostrum, mercury, to which he had the 
greatest aversion. "Your disgusting preparations are good for nothing. Medi- 
cine is a collection of blind prescriptions, which destroy the poor, sometimes 
succeed with the rich, but whose whole results are more injurious than useful 
to humanity." But he got mercury, notwithstanding, mercury for his *' digestive 
organs;" to '* excite the liver;" to "remove its obstruction," and mercury to 
create bile, and purgatives to remove it; and tonics, and antacids, and stimulants; 
and he died in torture, and his body was opened, and the stomach was found 
^^ cancerous." 

I should not omit mentioning to you, that in those cases of chronic gastritis, 
which run on to an incurable stage, the best treatment consists in a careful re- 
gulation of diet, in keeping the bowels open by enemata, or the very mildest 
laxatives, and in avoiding every thing capable of producing excitement. You 
will also derive advantage from the employment of gentle counter-irritation, 
and from the internal use of narcotics, which in such cases appear to have a 
more beneficial effect than any other class of remedies. With the exception of 
these, I do not know any other kind of medicine you can safely employ? and I 
believe that, in the majority of cases, you will find that the patients have taken 
already a great deal too much medicine. Anxious for relief, and urged on by 



214 QUARTERLY PERISCOPE- 

the hope of obtaining- some remedy capable of alleviating their sufferings, they 
have recourse to every grade of quacks, are persuaded to swallow every kind 
of drug, and are subjected to every form of harassing and mischievous treatment. 
The diet which you prescribe for such patients should be sparing but nutritive; 
give tile stomach as little to do as will be consistent with the support of life and 
strength; and you may take it as a general rule in the treatment of all chronic 
affections of the digestive tube, whether cancer of the stomach, scirrhus of 
the pylorus, or structure of the intestines, that there are two great principles 
of general application, preserving a gently open state of the bowels, and allay- 
ing inflammatory excitement. — Lond. Med. and Surg. Jour?i. Feb. Sth, 1834. 

23. Oh Duodenitis. By William Stokes, M. D. — I shall not dwell on the sub- 
ject of duodenitis, as I shall revert to its consideration when speaking of jaun- 
dice, because inflammation of the duodenum is a common cause of jaundice, 
perhaps the most common, if we take the whole of its causes together. You are 
not to suppose that I wish to inculcate the doctrine that jaundice is a necessary 
complication in duodenitis, but it has been proved, that there is an extraordinary 
frequent coincidence between both, and that jaundice very often seems independ- 
ent of any mechanical cause, such as an obstruction of the biliary ducts. So far 
from this that in some cases, particularly those which are produced by, or ac- 
company, a duodenitis, we have intense universal jaundice at the same time that 
the bile is flowing freely into the digestive tube. 

The researches of the immortal Bichat gave the first hint which directed the 
attention of practitioners to the circumstance, that, in many cases where jaun- 
dice had existed during life, there was no obstruction or disease in the liver or 
biliary ducts, but that in such cases there was always more or less inflammation 
in that part of the digestive tube, into which the bile was immediately discharg- 
ed, and this led ultimately to the discovery of the connexion which exists be- 
tween inflammation of the duodenum and jaundice. In treating of the sympa- 
thies which depend upon continuity of surface, Bichat refers to the connexion 
which exists between the surfaces of mucous membranes and the ducts which 
open on them, and endeavours to show, that the natural mode of excitement 
in all secreting glands is a stimulus applied to the surface on which their ducts 
open. As examples of this, he instances the effect which food and other sub- 
stances, applied to the mucous membrane of the mouth, have in stimulating the 
salivary glands; the effect which stimulants, applied to the conjunctiva or nose, 
have on the lachrymal gland, and many others. Hence Broussais concludes that, 
when the mucous surface of the duodenum is thrown into a state of excitement, 
we may have a consequent affection of the liver, for the duodenum bears the 
same relation to the liver as the mouth does to the parotid glands. That this is 
frequently the case, I think, is very probable. It is now estabhshed, that the 
cause of the yellowness in what has been called yellow fever, is disease of the 
upper part of the digestive tube, in which the duodenum is always involved; 
and that the fever itself, (the typhus icterodes of the nosologists,) has been 
found to be greatly connected with inflammation of the stomach and duodenum. 
During the epidemic of 1827, we had in the Meath Hospital a great many cases, 
which bore a striking resemblance to the yellow fever of warm countries, and 
particularly in this, that they were accompanied by intense jaundice, and in- 
flammation of the upper part of the digestive tube. You will see in the works 
of Rush and Lawrence, two of the best American writers on j'^ellow fever, that, 
of the numerous bodies they examined, there were scarcely any in which the 
jaundice was found in connexion with liver disease, but that in all cases there 
was intense inflammation of the digestive surface. — Ibid. 

24. On Inflammation of the Jejunum. By William Stokes, M. D. — We know- 
very little of the symptoms which characterize inflammation of the jejunum; 
and it is a curious pathological fact, that this portion of the intestinal tube is of 
all others the least liable to inflammation. In point of fact, we have no means 



Pathology. 215 

of ascertaining what are the prominent symptoms of inflammation of the jejunum, 
because, in almost every case in which jejunitis has been discovered, there has 
been also extensive disease of the rest of the small intestine. We have cases of 
simple g-astritis; there have been also cases of distinct disease of the duodenum. 
"We may have disease in the lower third of the ilium, unaccompanied by an 
affection of any other part of the tube. The same thing may occur in the case 
of the coecum, colon, or rectum, but it seldom or never occurs so far as the 
jejunum is concerned. — Ibid. 

25. On Inflammation of the Ileum. By WiLtiAivr Stokes, M. D. — Inflammation 
of the ileum is a most important affection, for two reasons; first, in consequence 
of its extraordinary frequency, and, in the next place, of its insidious latency, 
the disease generally requiring a considerable degree of tact and experience on 
the part of the practitioner to make out its diagnosis w^ith certainty. In fever, 
it is the most frequent of all the forms of intestinal inflammation; and hence 
Broussais, finding inflammation of the ileum of such constant occurrence in 
fever, concluded that fever was only symptomatic of intestinal inflammation. 
Further researches have shown that he was mistaken, and that the inflamma- 
tion of the digestive tube is, in many cases, secondary; but it is still a circum- 
stance of almost constant occurrence, and in many cases of fever is the cause of 
death. Now, the portions of the intestinal tube most commonly affected in fever 
are, the stomach and lower part of the ileum, and the frequent occurrence of 
this in fever is very remarkable. There are few cases of typhus without it. In 
some cases of typhus you will, on examination after death, be astonished to find 
extensive disease of the intestinal canal, vi'hich, during life, had not attracted 
5iny particular notice, and this you will most commonly find in the lower part of 
the ileum. So common is it, that Louis says that ileitis is the grand anatomical 
feature of typhus fever; that is, had he been obliged to pitch on the lesion of 
some particular organ as giving a character to typhus, he would say that it was 
ileitis. There are other diseases, too, in which inflammation of the ileum forms 
the principal complication. In the diseases of children, which go by the names 
of worm fever, remittent fever, and bilious fever, I believe that ileitis is gene- 
rally the first affection, and that the fevers are only symptomatic of it. It con- 
stantly occurs at some period or other of tabes mesenterica; and I believe, that 
in many cases it precedes the affection of the mesenteric glands. It is exceed- 
ingly common in phthisis. In every case of phthisis, where diarrhrea has lasted 
for some time, the probability is, that there is ulceration in the coecum, colouj 
and lower part of the ileum. 

Now, what is the nature of this ileitis? This preparation, f handing one for 
inspection, J which I beg of you to hand round, will furnish a very good illus- 
tration of the disease. Here is a portion of the intestine exhibiting various dis- 
tinct ulcerations of different sizes, occupying the situation of the mucous glands. 
I do not mean to say, that the character of the disease consists in this distinct 
ulceration; it is an essential disease of the mucous membrane, and of its glands, 
which exist in great numbers on the surface of the lower third of the ileum, and 
are called solitary and aggregate. These glands frequently take on the inflam- 
matory condition, become softened, run into ulceration, and produce extra- 
ordinary sympathetic irritation of the whole system. Tiiere has been lately a 
great deal of discussion with respect to the question- — Whether disease begins 
in the glands or in the mucous membrane, and whether we can separate disease 
of the glands from disease of the mucous membrane. This has been carried to 
a great extent; and a change has been attempted to be made in the name of 
the disease, it being entitled doihin- enteritis by those v»^ho say that the inflam- 
mation commences in the glands. But this I think is a m.ere refinement, and 
is carrying the thing too far. It is next to impossible for the glands to be af- 
fected without involving the mucous membrane, or for the mucous membrane 
to be affected without an extension of the disease to the glands. We some- 
times, however, see the mucous membrane diseased without the glands being 



216 QTTARTERLT PERISCOPE. 

apparently engaged; but I think the glands are never engaged without the co- 
existence of disease in the mucous membrane. In this preparation you see the 
mucous membrane is just giving way? and here is an actual slough, where the 
mucous and submucous tunics have yielded to the inflammation. In the lower 
portion of the ileum we meet with an infinite variety in the size and number 
of the ulcerations: in some they are very close and numerous, in others there 
are only two or three detached ones; in some, the whole circle of the intestine 
is destroyed, and the ulcer is nearly as broad as the palm of the hand. It is in- 
teresting to consider, with respect to the pathology of the respiratory and di- 
gestive systems, how it comes, that ulceration of the mucous membrane is so 
much more common in the digestive apparatus than in the respiratory. For one 
ulceration of the bronchial mucous membrane from acute disease, you will have 
one hundred of the gastro-intestinal. For this peculiarity we cannot clearly ac- 
count; but there seems to be more development in the digestive than in the 
respiratory system, and that this over-development produces a tendency to dis- 
ease. This, perhaps, is an approximation to an explanation of the facts; and 
to this may be added, that the mucous membrane of the intestines is exposed 
to the influence of a much greater variety of agents. It is difiScult to give an 
accurate idea of the symptoms of ileitis, as we can only arrive at a knowledge 
of it by negative evidence, or, as the French term it, *^ par voie d' exclusion. '' 

In a case of gastritis and of inflammation in the upper part of the digestive 
tube, the most prominent symptoms are thirst and vomiting. In this affection, 
too, there is thirst, but it is by no means so urgent as in the former cases, and 
there is generally no vomiting. In a case of acute gastritis there is always a 
desire for cold drinks. In this disease there is also a desire for fluids, but the 
patient prefers them warm. Here you perceive two symptoms, connected with 
the predominance of disease in the upper part of the digestive tube, are ab- 
sent — vomiting and the desire for cold drinks. 

Now, you are aware, that, in a case of inflammation of the colon and rectum, 
the most prominent symptoms are diarrhoea, tenesmus, and the passing of a 
quantity of morbid secretions. These symptoms, in a case of ileitis, are either 
wanting, or they are so slight as to excite but very little notice. If then, in a 
case of intestinal disease, we abstract the characteristic symptoms of disease in 
the upper and lower part of the digestive tube from the phenomena of the ex- 
isting disease; if we find that it presents symptoms which do not properly be- 
long to either the stomach, duodenum, colon, or rectum; we conclude that it 
must depend on a lesion of the remaining part of the canal, and we are, in this 
way, led to the diagnosis of ileitis. Let us enumerate the symptoms of an ileitis. 
In the first place, thirst, without a preference for cold drinks; in the next, ab- 
sence of vomiting; again, in the early period of the disease, there is generally a 
tympanitic state of the belly, and the patient seldom complains of pain even in 
fatal cases. This is a point of extreme importance. There is, however, most 
commonly a degree of tenderness over the ileum, which you will be able to de- 
tect by an accurate examination, and this tenderness presents a remarkable dif- 
ference from the tenderness of gastritis, both in degree and situation. It is very 
seldom so exquisite as in a case of gastritis, the patient can bear a considerable 
degree of pressure, and the tenderness, in place of being towards the epigas- 
trium, is situated between the umbilicus and the crest of the ileum on the right 
side; here pressure excites pain. The tongue in this affection is generally of a 
dirty -white, pointed, and red along the edges and tip; the pulse is quick and 
small, and the face is contracted. As to the nature of the discharges from the 
bowels they are exceedingly various; there has been as yet no diagnosis found- 
ed on their appearance, and in some fatal cases they have been observed to re 
tain an almost perfectly healthy appearance throughout. What would the gen- 
tlemen, who draw their diagnosis from chamber pots, say in such cases? I have 
seen perfectly natural stools in cases, which immediately after have terminated 
fatally, and where, on examination after death, there was a vast extent of ulcera- 
tion in the ileum. In addition to the symptoms just recited, the patient most 



Pathology. 217 

commonly \\&5 fever, and this presents itself under various forms, frequently as- 
suming the type of a simple continued fever; hence, in a great many cases, the 
patient is supposed to labour under merely simple continued fever, and the existence 
of extensive inflammation of the ileum is entirely overlooked. In other instances, 
there is more or less prostration, which increases with the progress of the dis- 
ease, and the fever frequently receives the appellation of typhoid. Under these 
circumstances, the patient often gets bark and wine, every means is taken to 
support his strength and remove the typhoid condition of the system, the in- 
flammation of the intestine is exasperated by neglect and mal-treatment, the 
patient dies, and, on dissection, the ileum presents an enormous sheet of ul- 
cerations. 

In cases of this kind, where the diagnosis depends as much on negative as on 
positive circumstances, it is of importance to have a direct sign, by which we 
may be able to ascertain with some degree of certainty the existence of a sus- 
pected enteric inflammation, and 1 think I have discovered one, which 1 be- 
lieve has not been as yet noticed; this is increased pulsation of the abdominal 
vessels. In many cases of acute inflammation of the brain, the increased pulsa- 
tion of the carotids has been frequently remarked, and every one sees that, 
under such circumstances, there is an undue excitement of these vessels, or, in 
other words, that there is a want of proportion between the action of the ca- 
rotids and that of the arteries of the extremities. If your finger be attacked by 
paronychia the same phenomenon is observed, the artery leading to the inflam- 
ed finger beats much stronger than the artery of the corresponding one on the 
opposite side. From these circumstances I was led to conclude that, in cases 
of acute inflammation of the digestive tube, there v.'ould be increased pulsatioa 
of the abdominal aorta; and, on following up the investigation, by examining 
several persons who had distinct and well-marked intestinal inflammation, I 
found that my conclusions were well-grounded. In such cases, I found not only 
a remarkable throbbing of the abdominal aorta, but I also discovered that this 
throbbing was prolonged to the femoral arteries, and that, on the other hand, 
there was little or no corresponding excitement in the arteries of the upper ex- 
tremities. 

In inflammation of the ileum the patient generally lies on his back, and avoids 
motion as much as he possibly can, his skin is dry and harsh; he is feverish; he 
has thirst, but little desire for cold drinks; he scarcely ever vomits; his alvine 
dejections are sometimes thin and purgative, sometimes figured and natural. 
But there is one circumstance which is of considerable importance in pointing 
out the amount of disease, even in cases where patients have considerable di- 
arrhcEa, and this is, that the diarrhoea is not sufficient to account for the extra- 
ordinary prostration. There must be some cause for the great reduction of vital 
power besides the mere diarrhcea, and I must state to you that there are few 
diseases which bring on such rapid prostration as inflammation of this portion 
of the digestive tube. In the advanced stage of this disease, the patients have 
cold skin, subsultus tendinum, petechise, involuntary discharge of urine and 
faeces, low delirium, coma, gangrenous ulcerations of the back, sinking of the 
powers of life, eff'usions into the head and chest, in fact all the symptoms which 
characterize the last stage of typhus. Generally speaking, the disease is more 
or less prolonged, and the patients die of exhaustion, but in some cases the ap- 
proach of death is more sudden and formidable. Some of the ulcers pass deeply 
into the substance of the intestine, perforate all its coats in succession, the con- 
tents of the intestine escape into the peritoneum, and the patient is carried off 
by a rapid peritonitis. — Ibid. 

26. Tnflainmation of the Ileum in Children. By William Stokes, M. D. — 
Inflammation of the ileum is very frequently met with in children, and it is 
most important that you should be aware of the extreme frequency, as well as 
the symptoms of this disease, in those little creatures. There is one fact in pa- 
thology which seems not to be generally acted on, that there is a class of dis- 

No. XXIX.— November, 1834. 19 



218 QUARTERLY PERISCOPE. 

eases which are intra-uterine, and with which a child may be born. There are 
a great many cases of this kind on record, but still I must confess, there is a 
great scojje for investigation, and that our knowledge on this subject is imper- 
fect. I believe that any one who has the opportunity of dissecting- a great 
number of still-born children, or of those who die immediately after birth, 
would, by examining- the state of the different cavities, and publishing the re- 
sults of his examinations, earn for himself very great reputation. It is a well- 
known fact that children may be born with hydrocephalus, with tubercles in 
the lungs, with acute inflammation of the stomach; nay more, children have 
been known to be born with chronic gastritis, and with old ulcerations in the 
ileum and colon. When children happen to be born with gastro-enteric dis- 
ease, they are puny and weak; the tact of this occurrence is generally over- 
looked, the case is considered to be one of general debility, and hence most of 
those children are lost in consequence of their medical attendants being igno- 
rant of the real nature of the disease. It is a very curious fact, too, that where en- 
teric disease occurs in very young children, it is frequently met with without any 
accompanying fever, and this is a point of great importance. Here is a fact not 
generally known. A new-born infant has vomiting, swelled belly, contracted 
features, but at the same time he has cold skin and feeble pulse; he has no dis- 
tinct symptoms of fever, and a puny and feeble state of constitution appears to 
be the prominent symptom. He dies, and, on opening the body, you find dis- 
tinct traces of enteric inflammation. The younger the child is, the less will 
be the chance of fever occurring as a sign of enteric inflammation. It seldom 
happens that this takes place after dentition, but before it is very common. 

Now, what are the circumstances which would enable us to recognise this 
disease in children who have passed the period of first dentition? If you find 
the child vomiting, thirsty, with swelled belly, hot skin, a tendency to diar- 
rhoea, and an erythematous redness about the anus, you may be sure that there 
is disease of the digestive system; if the child is restless, and you perceive 
that the symptoms of irritation of the head are coming on, you will be more 
certain, and in such cases pathology will inform you that the disease is chiefly 
in the ileum. In the advanced stage the diarrhoea is lessened, but the belly 
continues tympanitic, the child exhibits traces of long suffering, and the cir- 
cumstance of the teeth not being developed gives it the appearance of prema- 
ture old age, which cannot be mistaken by an experienced eye, and is a sign 
of long-continued and extensive intestinal disease. In some cases, the child 
gets a common attack of diarrhoea; this is neglected, but after going on for two 
or three days, symptoms of fever begin to appear. Here we arrive at a prac- 
tical rule. Where a child has diarrhoea, and after labouring under this for a few 
days, gets an attack of fever, you may be almost sure that it is a case of en- 
teritis, and that you will be acting wisely in treating it as such. In the opinion 
of many well-informed practitioners, that form of fever which has been called 
infantile remittent, is only an example of this disease. In proof of this fact. Dr. 
Marsh, my friend and predecessor in this school, in his paper on jaundice, 
makes some excellent remarks on this subject. "There is yet one form of 
disease of very frequent occurrence, the seat of which is in the stomach and 
small intestines. That to which 1 allude is the infantile remittent fever, or, as 
it is vulgarly termed, the luorni, fever of children. Its characteristic symptoms, 
if closely analyzed, vi'ill be found all of them to point to the mucous surface as 
the original seat of morbid action.'' — Dublin Hospital Reports, Vol. III. 

It would be well for medicine, if the valuable information conveyed in Dr. 
Marsh's paper was more universally diffused. 1 feel convinced that many chil- 
dren fall victims to mal-practice under circumstances of this kind. A child 
gets symptoms of diarrhoea, has irregular or bad appetite, and swelled belly, 
the disease is called worm fever; he gets a dose of calomel and jalap, and per- 
haps passes some worms; for when we come to speak of worms, we shall find 
that disease of the mucous surface is intimately connected with worms, and, in 
the opinion of one practitioner, worms may be the result of enteric inflamma- 



Pathology, 219 

tion. Well, some worms are passed; the purgative is again used; the child may 
not pass any more, or he may pass one or two in the week to encourage the 
practice. JBut all the symptoms of intestinal inflammation, the diarrhoea, the 
tympanitis, the thirst, the fever, are supposed to depend upon the presence of 
more worms, and these are to be evacuated by purgative medicine, and thus 
the affair goes on until the child falls into tabes mesenterica, or gets sympathetic 
inflammation of the brain, and dies of hydrocephalus. 1 regret to add, that m 
many cases of this kind the head alone is opened; a little fluid is discovered in 
the ventricles of the brain, the doctor's diagnosis of the head is found to be cor- 
rect, and all parties are satisfied. In cases of this kind, the early application 
of leeches to the belly, the regulation of diet, keeping the bowels gently open 
by enemata and mild counter-irritation, would have saved the patient. This is 
not mere tlieory, it is but a statement of facts, supported by the experience of 
practical men.— Ibid, Feb. 15th, 1834. 

27. On Tabes Mesenterica. By William Stokes, M. D. — The term tabes 
mesenterica is empIo3'ed to designate that species of consumption which de- 
pends upon disease of the mesenteric glands. The common idea formerly en- 
tertained with respect to this affection, and, I believe still to a great extent, is, 
that tile disease first commenced in the mucous glands, and from these extend- 
ed to the lymphatic ganglia of the mesentery, which in their turn became en- 
larged, thickened, and less pervious, so that a sufficient share of nutriment can- 
not be absorbed, the consequence of which is that the patient dies of atrophy 
and exhaustion. With such views of the case, the principles of treatment con- 
sisted in employing a class of medicines called deobstruent, the operation of 
which was supposed to be efficacious in removing this obstruction, this deposi- 
tion in the substance of the mesenteric glands, and the enlargement by which 
it was accompanied. This was, and this, I am sorry to say, is the idea still en- 
tertained by many. What is the actual state of the science with respect to this 
disease? It is found that the glands are certainly changed in their structure, 
and that they are manifestly enlarged; but this is only a link in the chain of 
phenomena, for it has been proved that in the majority of cases the disease is ush- 
ered in by enteritis, and that the swelling of the glands is the result of disease, pro- 
pagated along the course of the lymphatics from the mucous surface of the intestines 
to the mesenteric ganglia. This preparation, which I shall send round, will give 
you an idea of the actual state of the disease. Here is one of the glands which has 
been cut through; it exhibits the cheesy texture commonly observed in this 
disease, but you can perceive there are a number of lines running towards each 
of the glands; these are the engorged lymphatics, which you see correspond 
with ulcers on the mucous surface of the small intestine. That this is the true 
pathology of the disease will appear from the following circumstances: First, 
It has been proved that the glands of the mesentery commonly become in- 
flamed, enlarge, and even suppurate, in cases of inflammation of the mucous 
membrane of the intestinal canal in the adult. A patient gets enteric inflam- 
mation and dies; on dissection we find distinct marks of disease in the intes- 
tines, and, in addition to this, we find the glands evidently diseased. Here is 
one fact. In the next place, it has been proved that in a great many cases of 
tabes mesenterica, if you retrace the history of the disease, if you go back to 
its first and earhest phenomena, you will find that it began with the symptoms 
of what has been termed remittent fever, or that the patient had enteritis or 
diarrhoea, which afterwards became chronic, and that then the symptoms of 
tabes mesenterica began to appear. In the third place, you will find that in a 
vast number of cases, where a fatal termination has occurred, if you pursue 
your dissection, and slit up the whole of the ileum, you will discover numerous 
old ulcerations of the mucous membrane, and find that the lymphatics which 
correspond with these ulcerations are in a state of manifest disease. Lastly, it 
has been observed, that the best treatment for tabes mesenterica, is that which. 
is calculated to remove enteric inflammation, and that the old treatment, founded 



220 QUARTERLY PERISCOPE. 

on the principle of removing" obstruction by the use of alkalies, absorbents, and 
solvents, is erroneous and false in the majority of cases. So that we have proof 
of the origin of this disease in intestinal inflammation, drawn from the occur- 
rence of analog-ous affections in the adult, from the phenomena of ihe disease 
in its early stage, from morbid anatomy and from treatment. I think there can 
be no doubt that in most instances it commences by intestinal inflammation. Of 
course a predisposition to disease of the glandular system will favour the oc- 
currence. But is there no case in which the disease has commenced in the 
glands, and where the mucous membrane of the digestive tube is secondarily 
engaged? My answer to this question is, in a few cases we cannot prove that 
the disease commenced in the mucous membrane, and there is no reason why 
the glands of the mesentery should not be liable to primary tuberculous or 
scrofulous deposition as well as those of any other part of the body; but, in a 
vast number of instances, the enlargement of the mesenteric glands is se- 
condary, and resembles the inflammation of the inguinal glands which results 
from chancre on the penis. I would advise you to consult the Commentaries 
on Pathological Propositions by Broussais. On this subject, also, Dr. Mack- 
intosh's Practice of Physic. 

There is one thing more connected with this disease, which is of considerable 
importance, and to which I shall briefly draw your attention, and this is, that this 
inflammation of the glands of Peyer and Brunner, this dothin-enteritis, as it has 
been called, is a very common cause of slow convalescence in fever. You will 
meet with cases of fever which will go on to the 17th or 21st day, and then 
something like a crisis takes place; you expect that from this time forward the 
patient will get progressively better, but in the course of a few days you will 
be surprised to find no amendment, and that he is not gaining strength; you 
feel his pulse, and find it quick and small, his attendant informs you that he is 
restless at night, and when you ask him how he feels, he says he has no par- 
ticular complaint, but that he is very weak, gets no sleep at night, and has 
no appetite. Under these circumstances you are anxious to find out what his 
disease is; you inquire into the state of the heart, lungs, and brain; you find no 
evidence of disease in any of these organs; you run over in your mind the symp- 
toms present, the feverishness, quick pulse, want of appetite, restlessness, and 
finding some degree of abdominal tenderness and tympanitic swelling, you ar- 
rive at the conclusion, that the return of health and strength is impeded and 
delayed by the existence of a dothin-enteritis. The first person who discover- 
ed this fact was Dr. Cheyne. "In these cases," says he, "the distress of the 
patient often bore no proportion to the danger he was in; the former was very 
little, while the latter was extreme. The disease would proceed without vio- 
lent symptoms; nay, a patient would seem to be recovering, although without 
any critical discharge; he would call for full or middle diet, and for days take 
his food regularly. The only circumstance in his situation which demanded 
attention was that he regained neither flesh nor strength, and he expressed no 
desire to leave his bed. Then, his pulse again became quick and his tongue 
dry; and he would complain of dull pain and uneasiness in his belly, attended 
with soreness on pressure, and a degree of fulness in the upper part of the 
abdomen. Then came on a loose state of the bowels and great weakness. Pro- 
bably at the next visit the patient was lying on his back, with a pale, sunken 
countenance, and a very quick pulse; his mind without energy. Then his 
stools, (mucous,) passed from him in bed, and the urine also. Perhaps a hiccup 
came on; next his breathing became frequent, in which case death was at no 
great distance." — In all these cases the mucous membrane and glands were 
found in a state of decided disease. 

Now, what was the nature of this disease? It came on as a secondary affec- 
tion during the course of fever, became more marked and intense, and finally 
destroyed the patient. I have seen very many cases of this disease. I give 
you this as a general rule: — when, after the apparent termination of a fever, 
your patient convalesces very slowly and impex*fectly; when you find that he is 



Pathology, 221 

becoming weak, that his pulse is quick, his belly tympanitic, his thirst still 
present, and all this without evidence of disease in the respiratory, circulating, or 
nervous system, you may suspect inflammation of the mucous g-lands of the di- 
gestive tube, which may terminate in deep ulcerations; and you will not be 
surprised if your patient should be carried off by rapid peritonitis, occasioned 
by an ulceration of all the coats of the intestine. I have witnessed many in- 
stances of the truth of this statement. 

It has been objected to the doctrine that infantile remittent fever and tabes 
mesenterica depend on inflammation of the mucous membrane of the digestive 
tube, because it has been found that purgatives are sometimes useful in the 
treatment of the disease; and those who bring forward this objection ask, "if 
purgatives give relief, how can it be intestinal inflammation?" Now, what are 
the real facts of the case ? These cases, which have been relieved by purga- 
tives, are cases in which purgative medicine has been given in the early stage, 
and has been productive of benefit; or, in other words, where the disease is 
only just commencing, and where its cause is proved to be the presence of irri- 
tating matter in the bowels. A physician is called to a case of this kind; he 
gives a purgative; a quantity of offending matter is evacuated, and the child 
gets better. You should act in the very same way, and have recourse to pur- 
gatives v/henever you have reason to suspect the existence of irritating or indi- 
gestible matter in the bowels. You are to employ purgatives on the same prin- 
ciple as every one employs emetics, in cases where corrosive poison has been 
swallowed; but no one is inclined to think that he will be able to cure the dis- 
ease by the continued use of emetics. But, unfortunately, persons do not attend 
to the actual state of the digestive tube; they go on prescribing purgative after 
purgative, until the irritation, which was originally produced only by indigesti- 
ble matter, becomes exacerbated, and terminates in ulceration of the intestinal 
mucous surface, accompanied by all the symptoms of tabes mesenterica. — Ibid, 

28. Diseases of the Large Intestines. By Wiiwam: Stokes, M. D. — You will see 
in the various systematic treatises on the practice of physic, separate descriptions 
of the aff^ections of this portion of the digestive tube, you will find diarrhcea in 
one chapter and dysentery in another, and you will observe, that a great deal of 
ingenuity has been expended in forming nosological diff"erences between these 
affections. I fear that much of what has been written respecting them is rather 
calculated to puzzle and mislead than to inform the student. Viewed anatomi- 
cally there is no essential difference. You may for every practical purpose 
place them in the same class, and consider them as the result of the same mor- 
bid condition of the same part, namely, an inflammation of the lower portion of 
the digestive tube. Some persons may quarrel with the term inflammation, — 
call it then irritation if you please, but the truth is, that it is disease of the lower 
portion of the intestine, the results of which are increased sensibility and altered 
secretion, and this description, I think, will fairly apply to one as well as the 
other. If a man has purging with fever and pain it is called dysentery, if he 
has purging without pain, and without any manifest febrile excitement, we call 
itdiarrhcEa. But, incases where persons have died, after having laboured un- 
der diarrhoea for a length of time, we generally find, on dissection, lesions of the 
mucous membrane of the intestinal canal, sufficient to account for death. There 
are some cases indeed, in which the mucous surface takes on a gleety discharge, 
similar to that which follows gonorrhoea, and under such circumstances you will 
not be able to discover any distinct anatomical evidence of diseases. These, 
however, are comparatively rare, and bear little or no proportion to those cases 
which present distinct traces of organic lesion, — Ibid. March Isf, 1834. 

29. On Dysentery. ^ By William Stokes, M. D.— The first principle I have to 
enforce on this subject — and you may take it as an observation based on the 
soundest pathology — is this, that dysentery is inflammation of the large intes- 
tine. In some cases it is complicated with fever, and in others with disease in 

19* 



222 QUARTERLY l»ERlSCOPE. 

the upper portion of the digestive tube; and I believe that those cases, which 
are termed epidemic dysentery^ are those in which this disease is combined with 
typhus fever, or with an extensive affection of the small intestine — where there 
is ileitis as well as colitis. I shall not take up your time with discussions respecting' 
epidemic dysenteries, or those of warm climates; it will be sufficient for the 
present to allude to that form of disease which is observed in this country. 

I have told you that dysentery is an inflammatory affection of the great intes- 
tine, and all the symptoms during life, as well as the phenomena revealed by 
dissection, tend to confirm this view of the subject. We often have fever be- 
cause the constitution sympathizes with the inflammation of an important organ; 
we have excessive pain and irritation of the intestine, in consequence of its mus- 
cular fibres being involved in the inflammation; and we have discharges of mor- 
bid, purulent and bloody secretion. You will now please to inspect this pre- 
paration, and hand it round. See the effects of dysentery — the extensive in- 
flammation, ulceration, and sloughing of the mucous membrane. Here is an- 
other preparation; you perceive the whole surface of the colon is covered with 
coagulable lymph, which, in some cases, forms a chief part of the dejections. 
Here is a preparation which exhibits extensive sloughing of the mucous mem- 
brane; its tissue, you see, is quite abraded and destroyed. Here is a prepara- 
tion of chronic dysentery, which presents a very curious appearance; the mu- 
cous membrane is finely mammilated, as it were, and it is stated on the label, that 
the process of cicatrization was going on. If you compare it with the others, 
you will find a remarkable difference. Here is another specimen of dysenteric 
destruction. 

Here, then, is a disease in which we have violent inflammation of the mucous 
membrane and submucous cellular tissue, and, in severe cases I believe, of all 
the coats of the great intestine, except the serous. Let us rehearse its symp- 
toms briefly. Fever of an inflammatory or typhoid character, great pain and 
excessive irritability of the great intestine, morbid discharges of purulent, 
bloody, and lymphy matter, twisting pains called tormina^ and frequently the 
absence of fjecal matter in the dejections. — Ibid. 

30. Destruction of the Central Substance of the Spinal Marrow. — M. Maison"- 
NEuvE has communicated to the Anatomical Society of Paris, the interesting, 
and perhaps unique case of a woman affected, at the age of twenty-six, with a 
paralysis of motion and sensation of the upper extremities and of motion alone 
in the lower limbs, coinciding with the destruction of the gray or central sub- 
stance of the upper portion of the spinal marrow to the extent of eight or nine 
inches: a species of accidental *^ syringo-mielie^" analogous in form to that some- 
times met with congenital. — Archives Gen. Feb. 1834. 

31. Cartilages not Susceptible of Inflammation. — A knee-joint affected with 
white swelling has been exhibited to the Anatomical Society of Paris, a part of 
the articular surfa'ces of which was destroyed, but there remained portions of 
cartilage which had preserved their physiological characters. This case, with 
many others of the same kind, has induced M. Cruveilhier to believe that these 
cartilages are not susceptible of becoming inflamed, and that they are mechani- 
cally destroyed in consequence of the alterations in the bone. — Ann. de la Med. 
Phys. Feb. 1834. 

32. Serous Apoplexy. — Various specimens have been presented to the Anato- 
mical Society of Paris to demonstrate that the serous effusion into the cerebral 
cavities is not the cause of apoplexy; but that it results from an affection of the 
encephalic organs, and that it is incorrect to make a species serous apoplexies. — 
Ibid. 

33. Seat and Nature of Gonorrhceal Orchitis. — The Journal Hebdomadaire, for 
the 17th of May last, contains an interesting memoir on this subject by Dr. 



Semeiology. 223 

Mahc-Moreau. The author maintains, we believe with justice, that hernia hu- 
moralis consists of an acute inflammation of the vasa deferentia, of the epididy- 
mis and tunica vag-inalis, and that this inflammation rarely extends to the sub- 
stance of the testicle. The truth of this view he considers to be demonstrated — 
1st. By anatomy, which teaches us that the testicle enveloped by a dense, elas- 
tic, and fibrous membrane, could not acquire three, four, five, six, and ten 
times its normal size, without being disorganized. 2d. By clinical experience, 
which has shown the existence of fluctuation, especially at the commencement 
and termination of the disease. 3d. Finally, by post mortem examinations, in 
which the testicle, which was supposed diseased, has been found healthy; 
whilst the epididymis and tunica vag-inalis have constantly presented pathologi- 
cal alterations, and that in the cavity of the serous membrane a fluid of variable 
colour, consistence and qualities have always been found. 



SEMEIOLOGY. 

34. Foramen Ovale remaining Open in the Mult. — That this does not necessa- 
rily occasion cyanosis sufficient proof can be adduced. M. Kibes exhibited to 
the Anatomical Society of Paris the heart of a man sixty years of age, in which 
the auricles freely communicated without there being any change in the colour 
of the skin. M. Reignier has also exhibited to the same society a heart, the two 
auricles of which communicated by a net-work with large meshes; but what 
was most curious in this heart, was a foramen of the size of a quill, by whicli the 
two ventricles communicated, thus offering a double passage for the mixture of 
the two kinds of blood; and yet even in this last case there had been no cyano- 
sis until towards the close of life. — Archives Gen. Feb. 1834. 

S5. Aneurism of the Aorta simulating Laryngeal Phthisis. — A woman, forty- 
eight years of age, who had been in ill health for ten months, was treated foF 
laryngeal phthisis. She had, in fact, pain in the larynx, cough, at times pa- 
roxysms of suffocation, analogous to those of croup, or of oedema of the glottis. 
The voice was feeble, interrupted, sometimes shrill. An attack of haemoptysis 
supervened on the 30th of March, 1831, and three days afterwards the patient 
unexpectedly died in a state of syncope; the haemoptysis which had been sus- 
pended having recurred. On post mortem examination, an aneurismal tumour 
of the size of a large turkey's e^^, was found upon the concave and posterior 
face of the arch of the aorta. This tumour communicated with the oesophagus 
by an opening of six lines. The left bronchus was flattened and almost obli- 
terated by the tumour; the recurrent nerve of the same side was atrophied in 
consequence of the compression to which it had been subjected, (whence the 
alteration in the voice;) the stomach and intestinal tube were filled with blood» 
All the other organs were healthy. — Ibid. 

36. Ossification of almost the whole extent of the Aorta and Pulmonary Artery 
taken for an Aneurism of the Heart. — The subject of this case was a woman, 
seventy-three years of age, who had been in ill health for five or six years, and 
who had had palpitations, oppression, paroxysms of asthma, &c. She died 
dropsical. In the intervals of the paroxysms the pulsations of the heart were 
strong, full, but regular. On post mortem examination there was serous 
effusion in the abdomen and chest; the pulmonary artery was ossified; the ossi- 
fications developed between the internal and middle coats of the arteries were 
exposed in many points, in consequence of the destruction of the internal 
membrane; they occupied the whole extent of the aorta from the concavity of 
its arch to the second lumbar vertebra, and pulmonary artery from its origin to 
its bifurcation. These arteries, which in the dead body are ordinarily found 
empty, were filled with black, coagulated blood. The heart was neither 



224 QUARTERLY PERISCOPE. 

dilated nor thickened; the tricuspid valve presented several small points of os- 
sification, as also one of the sig-moid valves of the pulmonary artery. 

The patient in this case presented all the symptoms of aneurism of the 
heart, although this organ was healthy. These symptoms of aneurism were 
produced; 1st, by the increase in the force and frequency of the contractions 
of the heart, rendered necessary to compensate for the loss of contractiUty in 
the arterial parietes; 2d, by the presence of a greater quantity of blood in the 
cardiac cavities, as well as in the surrounding organs. — Ibid. 
• — 

37. Particular Sound of the Heart. ^Fr of essov Puchelt has described under 
the name of heuknder ton a peculiar sound of the heart, which he ascribes to 
hypertrophy with dilatation of that organ, coinciding with an aneurismal con- 
dition of the origin of the aorta without enlargement of its orifice. This sound 
is analogous to that termed by Laennec bruit de soufflet sibilant ou musical, but 
which he observed only in the arteries, and the cause of which he could not 
explain, not having had any opportunity of making a post mortem examination. 
Hope designates this same i-honchus, musical bellows murmur, and considers it 
as a sign of an alteration of the valves, without however adducing in its support 
any anatomical proofs. — Gaz. Med. March 29tk, 1834. 

38. Softening of the Spinal Marrow simulating Aneurism of the Heart. — A 
woman, twenty-nine years of age, very subject to nervous affections, resulting 
from mental anxiety, died after four days residence in the Hopital St. Louis, a 
victim to violent dyspncea, accompanied with cardiac pain and strong, tumul- 
tuous, irregular, and extensive throbbing of the heart. On post mortem exa- 
mination, there was not found any lesion of the organs of the chest. Finding 
only some traces of congestion in the brain and nothing unusual in the abdo- 
men, the spinal column was next examined. This from the termination of the 
cervical portion to the spinal marrow was completely softened; the medullary 
substance was mixed with liquid and turbid blood; the membranes were con- 
gested in the same region, and the arachnoid slightly opaque. — Archives G^n. 
Feb. 1834. 

39. Pulmonary Tubercles simulating an Affection of the Heart. — When miliary 
tubercles are sufficiently numerous to occupy a great part of the parenchyma 
of the lungs, without rendering this tissue impermeable to air, the chest pre- 
serves it sonorousness; the expansion of the lungs is heard throughout the 
chest, and what strikes the observer, is the exaggerated action of the heart and 
the oppression. In general, it may be said, that many phthisical patients ap- 
pear at first to be affected with disease of the heart. M. Huguier has seen at 
the Hopital St. Louis, a woman treated for two years for hypertrophy of the 
heart, in whom a post mortem examination showed this viscus perfectly sound, 
and the tissue of both lungs crowded with granular tubercles, the largest of 
which did not exceed in size a pea. — Ibid. 



MATERIA MEDICA. 

40. Lotions for the Cure of Porrigo Favosa. — M. Dauvergne employs the 
following lotions in the treatment of Dartre crustac^e Jlavescente, f Porrigo 
/aws«, Bateman.) 1st. R. lodin. ^iij.; lodur. potass, ^vj.; Aq. distill, giij. 
M. 2d. R. Sulphuret potass, giv.; Aq. distill. Oss. M. 

These solutions are mixed in the proportion of a drachm or tea-spoonful of 
thefirst, with half an ounce or table-spoonful of the second; the whole in a 
bason of tepid or cold water, according to the indication.— Jowrn. de Pharm. 
Jan. 1834. 



I 



Materia Medica, 225 

41. Properties and Effects of the Digitalis Purpurea. — The Nos. of the 
Archives Gen6rales for January and February last, contain an interesting* memoir 
by M. JoNKT, on the Digitalis purpurea. From all the facts which this writer 
has collected, he infers — 

1st. That the powder and watery extract of digitalis, (he prefers the latter,) 
jnay be administered in doses as high as sixteen or eighteen grains, commencing 
with one grain, and daily increasing the dose, without in most cases producing 
marked disturbance of the digestive functions. That the alcoholic extract 
cannot be depended upon, and that the ethereal extract is the most uncertain 
preparation. The infusion he considers as the most active preparation, and 
the dry plant to be preferable to the fresh leaves. 

2d. That in a great majority of cases, digitalis employed in powder, aqueous 
extract, and especially in infusion, exerts an irritating action upon the digestive 
organs, always evinced by colic, diarrhoea, nausea, and vomiting. That the 
property of the digitalis in rendering the pulse slower is indisputable, and that 
the gastro-intestinal irritation does not prevent this result. That the respira- 
tion may be affected by the remedy, dyspnoea most frequently disappearing as 
the pulse diminishes in frequency. That a distinct disorder of the nervous 
system is rarely observed after the administration of digitalis. That the digita- 
lis really possesses hydrogogue properties; and that the decoction of this plant 
in the dose of from two to four ounces, applied to the abdomen, is a powerful 
diuretic, very preferable to the internal administration of other diuretics, be- 
cause it may be employed in all cases of gastro-intestinal irritation. 

3d. That palpitations of the heart, which are most frequently the prelude to 
a severer affection, ordinarily yield to the use of digitalis. That anasarca and 
ascites may be relieved by the judicious use of this plant, and that the success 
attributed to it in mania, haemoptysis, advanced phthisis, scrofula, and many- 
other diseases is certain. — Archives Gen. March, 1834. 

42. Ointment for the Cure of Porrigo. — The following ointment has been 
found by M. Biett more efficacious in the cure of porrigo than any other re- 
medy: — 55;. lodur. sulph. 24 to 36 grs.; Axung. '^].—Bull. de Therapeuiique. 

43. On Rhatany Root. By M. Soubeiraiv.- — Rhatany is one of those reme- 
dies to which the medical profession are much indebted, and it is considered as 
one of the best of the astringent class for internal use. It is important, how» 
ever, to obtain the expected results from it, that it should be used with proper 
precautions, and with a full knowledge of its powers. 

Vogel, Gmelin, Peschier and Tromsdorff, examined this root, and if some 
points connected with its analysis are not completely elucidated, yet its che- 
mico-medical history has been fully developed. Rhatany contains tannin \n 
three states: — 1st. Pure; in which case it is colourless, and possesses all its pe- 
culiar properties. 2d. In a state insoluble in water, resulting from the altera- 
tion of the tannin by contact with the air; in this state it has lost its solubility 
and astringency. 3d. In the form of extractive, this is a soluble combination of 
pure tannin with No. 2, and gives to the fluid preparations of rhatany their 
characteristic red-brown colour. This root also contains a small proportion of 
gum, a little fecula, some saccharine matter, and an acid whose properties are 
not yet fully determined. 

It is generally used in decoction or in extract, each of which forms may be 
moditied to meet the exigencies of the case. 

Water acts on rhatany root in different manners, according to the tempera- 
ture at which the preparation is made. The decoction is a fluid of a dark red 
colour and astringent taste, and which becomes more or less turbid on cooling. 
The infusion is much less highly cohjured. It is of a reddish-yellow; and judg- 
ing from its appearance alone, its efficacy would be said to be much inferior to 
that of the decoction, but on tasting the two preparations, another opinion 
would be formed. Notwithstanding the light colour of the infusion, its astrin- 



226 QUARTERLY PERISCOPE. 

gent taste greatly surpasses that of the decoction, and in fact is the most ener- 
getic preparation. When rhatany is placed in tepid water, this is absorbed by 
it, and dissolves all the soluble tannin, the gum and saccharine matter, but if 
its action be prolonged, the teguments of the fecula are torn, and the soluble 
matter enters into combination with the tannin and dissolves it; at the same 
time, the soluble tannin becomes saturated, as it were, with No. 2, spoken of 
above, and an additional quantity of this latter is formed by the oxidizing ac- 
tion of the air. The decoction is dark coloured, and at the same time but little 
charged with the active principle on the one hand, because the effects of tan- 
nin are diminished by its union with the insoluble matter and fecula, and on 
the other because the vegetable fibre becomes saturated vi'ith it, and contri- 
butes to abstract it from the solution. This solutionbecom.es turbid on cooling, 
by the precipitation of a part of the insoluble matter, and by the separation of 
tannate of starch, which is not soluble in water belov/ 122° F. 

The Codex orders the extract to be prepared by exhausting the root with 
alcohol at 22°, and evaporating this tincture to get rid of the vehicle. In en- 
deavouring" to ascertain why the Codex has made choice of alcohol, we have 
supposed it was with the intention of diminishing the chances of any alteration 
of the tannin, as the evaporation can be for the most part carried on in close 
vessels and at a low temperature. But we here have an instance of the incon- 
venience of adopting the best founded theoretical principles, when their ap- 
plications have not been confirmed by a special reference to existing circum- 
stances. 

I prepared four different extracts, one by decoction in water; one by infu- 
sion, another with alcohol at 22°, and the fourth with alcohol at 33°. I repeat- 
ed this with different roots, and obtained the following general results. Alco- 
hol at 33° and at 22°, furnished the greatest proportion of extract. The de- 
coction gave less, and the infusion a still smaller quantity; but when the medi- 
cinal value of these preparations are considered, the results are widely different. 
The extract by infusion contained 90 per cent, of soluble matter, that by de- 
coction gave 40 per cent, of insoluble remainder. In the alcoholic extract 
made with the excipient at 33° there was from 60 to 75 per cent, of soluble 
matter, this v/as rather less when alcohol at 22° was used. 

In the extract by alcohol at 33°, all the soluble matters contained in the root 
are to be found, with the exception of a small proportion of the gum and 
fecula; the evaporation being made in a closed vessel, the tannin was unalter- 
ed, and hence the extract represented all the pure tannin which the root origi- 
nally contained. Alcohol at 33° is in fact the vehicle which furnishes the 
largest proportion of tannin, but it then is mixed with the matters insoluble in 
water. 

That obtained by alcohol at 22° is very analogous to the preceding, except 
that it contains more of the gum. 

Decoction caused a great loss of tannin. Many circumstances combined to occa- 
sion this; the fecula which unites w-ith one part, the ligneous fibre which becomes 
saturated with it, and the prolonged action of air and heat, all tend to diminish 
the quantity in the preparation. The insoluble matter is here a mixture of two 
bodies; No. 2, which is soluble in alcohol, and the compound of tannin and 
fecula, which is not. 

The extract by infusion is richest in soluble matter, the water only takes up 
"U'hat is permanently soluble, and hence the extract itself is wholly soluble in that 
fluid, with the exception of the small portion which has become oxidized during 
the evaporation. 

It results from what has been said, that the extract made from the infusion is 
to be preferred, as it contains the greatest proportion of the active principle. 
At the same time, I would observe that the relative quantities of soluble and 
insoluble matters contained in an extract of rhatany are of course variable, as 
each root furnishes different proportions, and also that the manner in which 
the operation is conducted, materially influences the results. — Journ. of Phil. 
Coll. of P harm, and Journal de Pharmacie, Nov. 1834. 



Materia Med lea, 227 

44. Syrvp of Jsparagus. By A. Latour and Roziers. — Tlie syrup of as- 
paragus has justly obtained a high standing, from the marked sedative proper- 
lies it possesses. But its tendency to fermentation prevents its being kept for 
any time without its undergoing a great alteration, winch developes an unplea- 
sant putrid odour, and deprives it of all its medicinal properties. To obviate 
this, the Journal of Medical Chemistry of 1830, proposes to dry the shoots, 
and to make the syrup as it is wanted, from an infusion of the dry plant. 

This plan does not attain the desired result, as it is extremely difficult to dry 
these shoots, on account of their succulent nature, and also because the aroma- 
tic principle is destroyed by this process 5 we have endeavoured to discover 
some mode, which whilst it would enable us to prepare the syrup at any time, 
would also preserve the full qualities of the fresh plant. The following has ap- 
peared to us to completely fulfil these indications: — 

F reparations. — 1. The asparagus shoots are to be reduced to a pulp, and the 
juice separated by means of a strong press. The quantity of juice furnished 
by the early shoots, is generally equal to two-thirds of their weight; later shoots 
only afford about half their weight. 

The juice after having stood to settle, is decanted and weighed, then heated 
in a water bath to coagulate the alumine, afterwards filtered and evaporated to the 
consistence of honey; when a quantity of sugar equalin weight to the juice before 
concentration, is to be added. This aqueous saccharole is to be dried in a stove. 
2. To the marc or parenchyma is to be added two-thirds of its weight of 
alcohol at 30°, and the whole suffered to macerate for three days in a close 
vessel, then subjected to pressure through a linen cloth, and the same quantity 
of alcohol again added to the marc, and the mixture suffered to macerate till 
the next day, when it is to be boiled for five minutes, subjected to pressure as 
before; and the products of the two operations united together. 

This mixture is to be distilled till three-fourths of the alcohol employed has 
passed over; when it has cooled, the same quantity of sugar as above is to be 
added, and the alcoholic saccharole which results is to be dried. 

These preparations are to be kept in well-stopped bottles, and from them 
a syrup may be extemporaneously prepared at all seasons in the following man- 
ner. Equal portions of each are to be taken and dissolved at a moderate heat 
in half their weight of water. When the syrup has been heated to ebuUitionj 
it is to be withdrawn from the fire and strained. 

This syrup unites all the conditions required in good syrup of asparagus, and 
retains in the fullest manner the aromatic taste of the vegetable. The seda- 
tive properties of this syrup are much augmented in this preparation, as has 
been amply tested in practice. But in which of the principles peculiar to this 
plant does the sedative power reside? Numerous researches on this subject 
have been made by Mr. Johnson, who attributes it to a resinous body, from 
which he states that he makes his syrup. 

Anxious to verify this fact, and to possess a readily prepared syrup of aspara- 
gus, we made the following experiment, Mr. Johnson not having published his 
method of manipulation: — 

Thinking that the resinous substance would be found in the parenchyma of 
the asparagus after expression, as no trace of it was discoverable in the juice, 
we treated a certain quantity of this substance previously dried, with double 
its weight of alcohol at 31°. At the end of three days, the alcohol acquired a 
beautiful green colour. When boiled it deposited a great quantity of a green 
substance, part of which adhered to the sides of the vessel, and another floated 
on the surface in the form of globules. We separated this substance by decan- 
tation, and discovered with astonishment that this pretended resinous prmciple 
presented all the characters of a fixed oil. 

This oil is of a beautiful dark green colour, which, however, is very fugi- 
tive; for an alcoholic solution of it, exposed to the rays of the sun, soon lost its 
peculiar tint, and the oil which remained after the evapor^-tion of the men- 
struum, was only of a yellowish hue. It has a peculiar and powerful aromatic 



228 QUARTERLY PERISCOPE. 

odour, but a mawkish taste. It is somewhat viscous; at the temperature of 53** 
F., its consistence is that of a soft grease or of thick oil, which does not liquify 
till 75°. Placed in a tube, and cautiously exposed to the flame of a spirit 
lamp, it first assumes a reddish colour, and is then decomposed, affording" the 
usual products of the oils, and leaving- a tolerably voluminous charcoal. 

Water has no action on it — ether and the oils dissolve it in all proportions. 
Alcohol at 31° readily takes it up. Nitric acid dissolves it without apparent 
decomposition, as does also hydrochloric acid, which appears to heighten the 
colour. Sulphuric acid dissolves it, acquiring- a slight red tinge. By the action 
of a regulated heat, the colour becomes blood-red, and the solution is thicken- 
ed. Water precipitates it in a grayish form. 

The alkalies dissolve it rapidly, and the acids precipitate it from this combi- 
nation in white flocculi. All these characters demonstrate to us the existence 
of a fatty oil extracted by the alcohol. This appears to us to be possessed of 
important medical properties. 

It is certain that the syrup of asparagus, prepared either with the alcoholic, 
or with the aqueous saccharole, has a remarkably sedative property, in retarding 
the circulation and in acting specially on the heart. 

From what has been said, it results that the union of the two preparations 
enables us to obtain the whole of the sedative principles of this substance. 
Moreover, pastilles may be made which may render the administration of this 
remedy more easy. We propose the following formula for them: — 

Saccharole of asparagus, --.^---2 parts 

Sugar in fine powder, Ido. 

Mucilage of gum Arabic made with orange flower water, - Q. S. 

Make pastilles of twenty grains. 

These pastilles should be kept in a well-stopped bottle in a dry place, as they 
are apt to attract moisture. 

A jelly may also be made with this saccharole by adding a solution of icthyo- 
colla to it. This forms an agreeable compound which might be advantageously 
used as an article of diet. — Journal de Fharmade, Bee. 1833. 



PRACTICE OF MEDICINE. 

45. Treatment of Ileitis. By Wm. Stokes, M. D. — Laxatives are to be employed 
in enteritis, on the same principle that emetics are used in cases where corrosive 
poison has been taken into the stomach. We are not to expect to be able to 
cure the disease by the use of laxatives, nor are we to have recoiu'se to them in 
every case; we employ these remedies where we have decided evidence of the 
existence of offending matter in the bowels. AVe may meet with a case in the 
early stage under such circumstances, that the removal of the irritating matter by 
judicious purgation may completely relieve tlie patient, and this, I believe, is 
the foundation on which the superstruction of the British purgative practice in 
ileitis and tabes mesenterica was raised. It was concluded, that a laxative 
treatment, which had on many occasions succeeded in removing the first symp- 
toms of the disease, would necessarily cure it in all stages and cases. This, I 
need not tell you, is wrong. Whenever you give purgatives or laxatives in 
enteritis, bear this in mind, that the effect which you have to produce is 
to be brought about at the least possible risk. If you can unload the bowels 
with a little castor oil or rhubarb, or some mild neutral salt, it is much better 
than to have recourse to calomel, or scammony, or colocynth. As a general 
rule, drastic purgatives must be avoided in inflammation of the mucous mem- 
brane of the intestines. The school of Broussais committed an error, on the 
one hand, by never admitting the use of laxatives, and British practitioners have 
been wrong, on the other hand, by giving too much purgative medicine. The 



Practice of Medicine. 229 

error of the latter arose from looking* always upon purgatives as antiphlog-istics, 
which they are certainly, so far as they contribute to relieve inHammaiion by 
causing an increased secretion from the intestinal mucous surface. But this in- 
crease of secretion can be produced only by stimulating the organ to which they 
are applied; and hence, before they can become general antiphlogistics, they 
must, of necessity, be local stimulants. Further; if in a case of inflammation of 
the digestive tube you prescribe a purgative, and it fails in causing an increase 
of secretion, it will add considerably to the existing inflammation. It is, 
however, of very great importance that there should be no accumulation of 
offending matter in the bowels; and hence, when you find a degree of fulness 
in the belly, and the dejections scanty, you should always give a laxative, and 
follow it up by the administration of a narcotic. By using enemata, you can 
do a great deal of good, and this without any injury to the digestive tube; and 
I think they may be always employed with benefit in disease affecting the ileum. 
Recollect, gentlemen, what I wish to impress upon you respecting this part of 
the treatment is, that laxatives are to be employed in ileitis as one of the 
means of cure; but you are not to expect that a cure by the use of these alone 
will always be a matter of constant occurrence. It is true, that many cases pre- 
senting symptoms of enteritis, have, in the beginning, yielded to laxatives; but 
it is true also, that horrible mischief has been done by their continued or indis- 
criminate employment. 

A few observations now with respect to bleeding. There is in simple inflam- 
mation of the mucous membrane of the intestines this peculiarity— it very sel- 
dom happens that it is necessary to use the lancet. The whole class of intesti- 
nal inflammations is so generally accompanied, even in the early period, with 
marked prostration and a typhoid condition of the whole system, that general 
bleeding is very seldom employed. But when the disease is recent, the con- 
stitution vigorous, the patient young, the skin intensely hot, and the pain vio- 
lent, (a combination of circumstances which is not of very common occurrence,) 
you may employ the lancet with safety and with great advantage to your pa- 
tient. But what I wish to impress upon you is this — you must not expect to 
cut short an attack of enteric inflammation by general bleeding. Over inflam- 
mations of mucous membranes in general, but particularly of the intestinal 
mucous surface, the lancet has comparatively but little direct power; it is in 
the inflammatory aff'ections of parenchymatous tissues and serous membranes, 
that we generally observe the most brilliant and decided eff"ects of venesection. 
Neither can you, as in parenchymatous inflammation, bleed a second and a third 
time with benefit. In cases of inflammation affecting the mucous membrane of 
the intestinal canal, you are to look upon venesection as a preparatory step to 
leeching. Where the pain is violent, the fever high, the attack recent, and the 
constitution strong, you will do well to bleed; but only bleed once, and then 
apply leeches in abundance over the suflTering organ. There is nothing of 
more importance, nothing of such decided value, as bleeding by leeches in 
inflammation of the mucous membrane of the intestinal canal, and Iiere we ar- 
rive at a fact, the explanation of which is involved in much obscurity. A pa- 
tient is attacked with inflammation of the mucous membraiie, and glands of tiie 
digestive tube, twelve or twenty leeches are applied to the integuments of the 
abdomen, and their application is followed by extraordinary relief. This is a 
very curious fact when we consider that between the place where we apply the 
leeches, and the tissue which is affected, there intervene skin, cellular mem- 
brane, superficial fascia, cellular membrane again, deep-seated fascia, muscular 
substance, cellidar membrane again, two layers of peritoneum, and muscular 
substance enveloped in cellular tissue. Yet, notwithstanding this extraordinary 
succession of tissues, it is an undeniable fact, that the application of a dozen 
leeches to the surface of the belly will frequently cut short an intestinal inflam- 
mation, or materially diminish its intensity. Here is a fact, the explanation of 
which is extremely difficidt; and I tell you candidly, I cannot explain it. The 
school of Broussais attempt to explain it as follows. They state that it is a con- 
No. XXIX.— November, 1834. 20 



230 QUARTERLY PERISCOPE. 

stant law of the economy, that there is a strong- sympathy betsveen the internal 
parts and their respective integuments, but thty do not say why this sympathy 
should exist. We frequently, however, observe facts confirmatory of this law 5 
you are aware that it often happens that, in cases of the deep-seated muscular 
phlegmon mentioned by Mr. Crampton, in abscess of the liver, and in empyema, 
we have a swelling of the integuments, showing the existence of a sympathy 
between the integuments and the internal organs. 

In treating a case of inflammation of the small intestine, I think you may 
generally commence with the application of twelve or eighteen leeches over 
the ileo-coecal region. The ordinary result of this application is, that the 
pain and tympanitis are reduced, and the thirst diminished; but the patient 
still has fever, and you are to bear in mind that the mere subsidence of pain 
does not imply the removal of the disease. We may modify the character of 
an ileitis very considerably by a single application of leeches, but we are 
not on that account to expect that we shall be able to remove the dis- 
ease entirely. In general it is necessary to apply them two or three times, 
lessening the number at each succeeding application, and takhig care that 
they are applied in the proper place, that is, midway between the um- 
bilicus and the crest of the ileum. Many practitioners are afraid of employ- 
ing leeches in the advanced stage of this affection, in consequence of the great 
debility, which characterizes the advanced stage of this, as well as inflamma- 
tion of every other part of the digestive tube. But though I am quite of opinion 
that the school of Broussais is wrong in using them at any period, still I think 
they may be employed even where the disease is advanced, particularly if they 
have not been used hefore^ and I have frequently seen leeches applied with ad- 
vantage as late as the twelfth day. T have employed them myself in the Meath 
Hospital, as late as the ninth and tenth days, with decided benefit. Many phy- 
sicians on the continent are in the habit of treating inflammation of the diges- 
tive system by the application of leeches to the anus, and this is said to have a 
very good effect, and the number of leeches required is smaller. In disease of 
the great intestine accompanied by diarrhoea, tenesmus, and tormina, I think 
this is an excellent mode, lout when the disease is in the upper part of the tube, 
I prefer applying them to the belly over the situation of the inflamed organ. 

Now with respect to internal medicines. In this disease every thing that is 
administered should be given with the view of removing irritation, and for this 
purpose I know no better preparation than a combination of ipecacuanha and 
opium, as in Dover's powder. The exhibition of the compound powder of ipeca- 
cuanha is attended with decided advantage. You are all aware of the long-es- 
tablished use of ipecacuanha and opium in diseases of the intestinal canal, and 
I think there can be no doubt that they possess considerable utility. With this 
I generally combine some mild mercurial; the best you can employ is the 
hydrarg. cum creta. Give two or three grains of each every second or third 
hour, as the case may be, and you may continue this for several days. Where 
there is no diarrhoea, and the bowels have a tendenc}^ to be constipated, it will 
be necessary to order, every second or third day, a mild laxative, a little man- 
na, or rhubarb, or some castor oil; you should insist on the daily use of enemata, 
and if they answer the purpose sufliciently I would advise you to be sparing 
of the use of laxatives by the mouth. In addition to these remedies, I am in 
the habit of giving- a considerable quantity of gum Arabic, which appears to 
have an extraordinary efficacy in disease of the small intestine. I look upon it 
as peculiarly valuable in the diseases of children. The ordinary mode of pre- 
scribing it is to give a certain quantity of gum water. If this is insufficient, 
you should order half an ounce or an ounce of the gum to be dissolved in a pint 
or quart of water, which the patient is to use during, the day. After the use of 
the hydrarg. c. creta and Dover's powder, this has a decided value in the treat- 
ment of ileitis. 

In this way, by leeching, mild laxatives, prescribing mercury with chalk, and 
compound powder of ipecacuanha with gum water, your patient begins to im- 
prove. The tenderness of the epigastrium disappears, the tongue begins to 



Practice of Medicine, 231 

clean, the fever diminishes, the thirst goes off, and appetite returns. This is 
the favourable termination. AVhen the patient is of a weak and dehcate habit, 
it is of g-reat importance to pay particular attention to supporting the strength, 
even from an early period of the disease. In such a case, after the first week, 
the physician who neglects the proper means of su[)porting his patient's 
strength does wrong, and it has been justly remarked, that a practitioner will 
be right in supporting the general strength, at the same time he is employing 
local antiphlogistics. It is in steering clear between these two opposite dan- 
gers that the judicious practitioner is seen; he does not allow his patient to die 
of inanition, while at the same time he takes care to remove local inflamma- 
tion. I have seen several experienced physicians prescribe leeches to the ab- 
domen on the same day that they ordered the patient to have chicken broth, and 
even a little wine. There is nothing improper in this; an inexperienced prac- 
titioner, who has his eye merely on the local inflammation, is apt to fall into the 
error of overlooking the constitutional debility, and allowing it to steal upon 
him. He finds very little difference between the appearance of his patient this 
day and the next, and thinks the slight increase of del)ility undeserving of any 
attention. At last his patient begins to sink visibly, he gets alarmed and has 
recourse to stimulants, laut it is now too late. Besides, there are several articles 
of diet which support strength, without increasing inflammation, as for instance, 
chicken broth, sago, arrow-root, strained rice, &c. These do no harm, and 
they prevent the patient from falling into a dangerous typhoid condition. Let 
us look at this in another point of view. Suppose you are called to a child who 
is said to have had an attack of worms, or bilious derangement, or that his bowels 
were costive, and purgatives w^ere given, that the discharges were found to be bad, 
and more purgatives were administered; or suppose you are called to a child of a 
weak scrofulous habit; who has been taking large quantities of purgative medi- 
cine, for what has been termed derangemeiit of the bowels, and you find the little 
sufferer with pale, shrunken face, a black circle round his eyes, cold extremities, 
rapid faltering pulse, great thirst, and evident symptoms of increased cerebral 
excitement; the little arms and hands are as cold as death, but the belly burning, 
tympanitic, and very sensible to pressure, and when you compare the radial ar- 
tery with the femoral, as it turns over the pubis, you will have some conception 
of the excited condition of the abdominal vessels; and in addition to this train of 
morbid phenomena, you find there is suppression of urine. Are you to attack 
these symptoms with antiphlogistic means'* No; the first thing you are to 
do, is to prevent any further mischief, by totally inhibiting every kind of 
purgative medicine. You are next to consider carefully what the best line of 
treatment to be pursued is, for here you are under circumstances of difficulty, 
and have a great many prejudices to contend with. What I find generally to 
be most successful is this. I begin by taking proper steps to support the 
strength, ordering the patient to take chicken broth, arrow-root, or jelly; the 
extremities are to be wrapped up in warm flannel; and if the patient is sink- 
ing, and has his mouth and teeth crusted with dark sordes, a little wine, watch- 
ing its effects. If it produces sleep, if the pulse comes down under its use, 
and the fever is not increased, it will do a great deal of good, and you can 
gradually increase the quantity. Always bear in mind, that there is a certain 
period in all inflammations, in which stimulants prove to be antiphlogistics, a 
circumstance which has been overlooked by the school of Broussais. So far with 
respect to constitutional treatment; but what will you do with local disease ? 
The application of blisters is of decided use, nay, I have seen a few leeches 
very effective. Apply a blister to the abdomen, and dress it with mercurial oint- 
ment, at the same time, you may employ frictions with mercurial ointment: 
you will also swathe the belly with flannel, so as to keep up a comfortable tem- 
perature. In this way you will be able to do a great deal of good. You will 
also prescribe hydrarg. c. creta, with Dover's powder; and if the bowels 
are confined, emollient injections. By steadily pursuing this plan of treat- 
ment, you will often rescue from imminent danger a case which would prove 



232 QUARTERLY PERISCOPE. 

fatal under the purgative plan, and you will add greatly to your own repu- 
tation. 

There is one form of this disease in which diarrhoea is a prominent symptom, 
where there is purging from the very commencement. On this form lam anxious 
that you should have clear ideas. In cases of this kind there is a copious dis- 
charge of fluid matter from the bowels. In the majority of cases, you may lay 
down this law, that where tliere is adecided irritation of any secreting organ, in- 
creased discharges from the surface of that organ give more or less relief. Sup- 
pose two cases of hepatitis? in the one we have no secretion of bile, in the other 
the secretion is copious; the latter is certainly most favourable. Again, sup- 
pose two cases of bronchitis; in one there is a copious expectoration, in the 
other it is extremely scanty; now every medical man knows that the former is 
more easily managed. The increased secretion of any organ in the early stage 
is to be looked upon as a relief to the inflammation. The practical inference 
to be deduced from this is, that we should be cautious in adopting any means 
of arresting tliis discharge, as it is one of the modes which nature employs in 
relieving the irritation of a suffering organ. Well, then, suppose you have a 
case of enteritis, and that on the first or second day diarrhoea sets in, what does 
the routine and systematic physician do? Fie gives chalk mixture and opium 
with tincture of kino and catechu, and what is the consequence? The belly 
becomes tympanitic; the pain is increased, and even peritonitis may supervene; — 
this is one result of the increase of inflammation; or the breathing becomes 
difficult, and the patient gets bronchitis or pneumonia. Diarrhoea occurring in 
the early period of this disease is not to be interfered with, except when it gets 
to such a height as to threaten the patient's life; and where it increases his suf- 
ferings by the frequency of the discharges. In the first week or fortnight, 
when there are only three or four discharges, or even five in the twenty-four 
hours, I believe it is better not to interfere by prescribing direct astringents; 
but in the advanced period, when th& powers of life, are low, or the discharges very 
copious, then the physician comes to the assistance of nature with just reason, 
and in such cases you should always interfere. The best mode of managing 
diarrhoea of this kind is to employ small, frequently repeated-doses of Dover's 
powder, with anodyne injections. And here I may mention briefly, to such of 
you as have not seen them used, the best way of employing them. As these 
injections are used on a different principle from the common, the latter being 
intended to empty the great intestine and be discharged, the former to be re- 
tained, we are consequently to make the basis of our anodyne injection in such 
a manner, that it will not prove stimulant from its bulk, or from any irritating 
substance it may contain. Mucilage of starch, new milk, or linseed decoction 
may be used as the basis, and the quantity taken for one injection should never 
exceed three ounces. To this, for an adult, you add from fifteen to thirty 
drops of tincture of opium, for it is a curious fact connected with this subject, 
that opium given by the rectum has frequently been observed to exercise a 
much more powerful effect on the system than when an equal or even 
smaller quantity has been taken by the mouth. The rule then is, that when 
you first make trial of the remedy in this manner, feel your way cautiously, and 
ifyou find that 3'^our patient bears tenor fifteen drops, you can increase the 
quantity on repeating the enema. An eminent practitioner of this city thinks 
the narcotic effect of opium by the rectum much better marked than by the 
mouth, and I believe this to be true in many instances. I believe the adminis- 
tration of opium in this way requires a good deal of caution. I recollect the 
case of a man who had been for a considerable length of time in the habit of 
using laudanum in large quantities, and was, in fact, a regular opium eater. 
During an attack of illness he got an injection containing sixty drops of lauda- 
num; this produced, in a very short time, symptoms of decided narcotism, 
from which the patient never recovered; in fact, he died with every appear- 
ance of being poisoned by opium. There is another fact with respect to this 
disease, which I would have you bear in mind, that, under certain circuna- 



Practice of Medicine, 233 

stances, inflammation of the small intestine will produce a remarkable toler- 
ance of opium. This applies not only to the advanced stage of enteritis, but 
also to many other forms of disease. Some time since I made a series of clinical 
experiments with the view of ascertaining* the power which opium possesses in 
relieving" inflammation, and the result has been, that in many cases where the 
powers of life are so low that we cannot have recourse to the lancet, or any kind 
of depletory measures, opium alone furnishes us with a powerful means of sub- 
duing inflammatory action. When we come to treat of peritonitis, I shall have 
occasion to speak of the good effects of very large doses of opium, particularly 
in that form of the disease which results from intestinal perforation. My first 
trials of this remedy were in affections of serous membranes, and to this I was 
led by some interesting clinical experiments made by Dr. Graves. I next tried 
it in diseases of mucous membranes, where antiphlogistics were inadmissible, 
and here, as in the former cases, I had many proofs of its great efficacy. I shall 
state the particulars of a very remarkable case. A young gentleman, a pupil 
of mine, and a member of the class at Park-street, of an irritable habit, was at- 
tacked with intense inflammation of the mucous membrane of the intestines. 
He had a high degree of fever, and his thirst was so insatiable, that for two 
days he never ceased calUng for drink. His pulse was weak but rapid; his 
tongue red and pointed; respiration very much hurried; but the stethoscopic 
signs of disease of the lung were absent. His belly was exceedingly tender on 
pressure; and he had another remarkable symptom — constant smacking of the 
lips. The case, as you may perceive, was one of severe gastro-enteritis, and 
it was treated in the ordinary mode, by leeclies, cold water, &c., but the dis- 
ease showed great obstinacy, and at the end of a month the patient was evi- 
dently in a state of imminent danger. At this period a curious revulsion took 
place: the chest became engaged, and the patient got bronchitis. For this he 
was blistered, and took the decoct, polygalse with large doses of carbonate of 
ammonia, under the use of which he recovered. The bronchitis disappeared, 
but was almost immediately replaced by symptoms of intense gastro-enteric in- 
flammation, thirst, quick pulse, tympanitis, low delirium, and subsultus ten- 
dinum. In the course of two or three days diarrhoea came on, becoming more 
profuse as it advanced. The first day he had four discharges, the next eight, 
and thus it went on increasing until there was a constant discharge of thin fluid 
matter from the anus. The patient was quite run down, and on three different 
occasions his friends thought him dead. Having made an unsuccessful trial of 
various stimulants and astringents, I determined to try what might be expected 
from large doses of opium. The patient was dying, and it was necessary to do 
something instantly, which would be likely to arrest the diarrhoea. I ordered 
a grain of opium to be given every hour; on the first day he took twelve grains 
with apparent benefit, the next day he took six, the same quantity on the third 
day, and on the fourth the diarrhoea had so much diminished, and the young 
gentleman was so much better, that I thought it might be safely omitted. From 
this period my patient recovered rapidly. I would not bring forward this case 
in proof of the efficacy of opium if there were not many others of a similar 
kind; and I have no doubt that this was a cure effected by the use of opium in 
large doses. In the treatment of this disease by opium, there is one simple 
rule, by observing which you will be able to avoid all difficulties, and at the 
same time have a criterion to judge of the value of the opiate treatment. If the 
remedy produces the ordinary narcotic effects of such large doses on the sys- 
tem, it will not do much good. You begin, therefore, cautiously; and if, after 
the first or second dose, you find that decided narcotism is produced, or at 
least more than you would think the quantity given could have brought on, give 
it up; — it will be dangerous. But if he bears one, two, or three grains, or if, 
after having taken six or eight grains in the twenty-four hours, he appears ta 
be improving, you may then persevere in the administration of opium, and it 
will be attended with decided advantaq:e. — Lond. Med. & Surs^. Journ.y Feb^ 
22rf, 1834. 

20* 



234 QUARTERLY PERISCOPE. 

46. Treatment of Diarrhoea. By Wm. Stokes, M. D. — Diarrhoea is the frequent 
passing of stools of a more or less watery consistence, and which may, and ge- 
nerally does occur without fever. This affection may be considered to arise un- 
der three different ch-cumstances, but, in point of fact, every form of the disease 
may be referred to a single cause, as there is no essential difference in the 
actual nature of the circumstances by which they are produced. A patient, for 
instance, takes a quantity of indigestible food, this produces irritation in the 
gastro-intestinal mucous surface, and diarrhoea is the consequence. Another is 
exposed to cold, or gets wet feet, the mucous membrane of the bowels be- 
comes more or less inflamed, and this terminates in diarrhoea. Again, a patient, 
labouring under hectic, has profuse perspirations, these go off and are replaced 
by frequent fluid discharges from the bowels, — here, also, the result is called 
diarrhoea. All these forms are, however, referable to the same cause, — irrita- 
tion of the mucous lining of the digestive tube. 

A man commits an excess at table, eats something that he cannot digest, and 
gets diarrhoea. If you happen to be called to such a case at an early period, 
your course is very plain and easy; there is every chance that the affected organ 
has received (as yet) no material injury, and it is attempting to relieve itself by 
increased secretion. The indication here is to get rid of the source of irrita- 
tion as soon as possible, and this is best done by prescribing a laxative to re- 
move the offending matter, and then following it up with an opiate. The simple 
rule is to relieve the intestine, and prevent the liability to inflammation. A 
mild laxative, followed by opiates and demulcents, keeping the patient on alow 
regimen for a few days, and in a warm temperature; this is sufficient for the 
management of the first form of diarrhoea. In point of fact, the principal 
thing, which the practitioner has to do, is to watch his patient, and take care not 
to permit the inflammatory action to become developed. It is in such cases as 
these that the expectant medicine is of value. "What you are to direct your 
attention to, is the state of the intestinal surface. If a patient gets an attack of 
pain, if his belly becomes tender on pressure, if he is more or less feverish, 
you may be sure there has been some mischief done. If, on the contrary, the 
diarrhoea yields to the exhibition of a mild laxative and light diet; if the pulse 
soft and the belly not tender you have no reason to fear. But if the purging 
becomes more distressing, if the pain is severe, the abdominal tenderness evi- 
dent, the thirst and restlessness continue unabated, it is a sign that the irritation 
has produced something more than mere increased secretion, and that actual 
disease of the mucous tissue is setting in. We have now a true inflammatory 
diarrhoea, which may be looked upon altogether as an enteritis of that kind, in 
which there is a copious secretion from the surface of the intestine. You ob- 
serve this leads us at once to the principles of treatment. Here we have fever, 
pain, frequent morbid stools, thirst, and abdominal tenderness. Well then, 
what are you to do? In a case where these symptoms are so severe as to excite 
alarm, at once begin by applying leeches. Where there is merely evidence of 
intestinal irritation caused by indigestible food, give a laxative, and follow it up 
with an opiate; where, in addition to the ordinary symptoms, you have fever, 
pain and tenderness, never omit the application of leeches. Many a time have 
I seen cases of this kind, in which chalk mixture and astringents not only failed 
but even caused additional suffering, speedily and completely relieved by the 
application of a few leeches. In using leeches, too, we are not, like the prac- 
titioners who trust to astringents, playing at the game of double or quits; nor 
do we stop the purging by exchanging it for something else equally bad, or 
even worse, for a peritonitis or a bronchitis for instance; hy removing its cause 
we not only check the diarrhoea,- hut we obviate any tendency to a metastasis of in- 
Jiammation to other tissues^ and our mode of cure has at once the merit of being suc- 
cessful and safe. 

A patient who has had an attack of diarrhoea should have his belly swathed 
with flannel;~this should never be neglected. He will also experience a great 
deal of benefit from the use of the hip bath and occasional opiates. Give also 



Practice of Medicine, 235 

a combination of rhubarb and Dover's powder, and you will find that it will 
do him a great deal of good. This is the remedy which Rhsederer and Wscgler 
found to be of extraordinary advantage, in the mucous fever with diarrhoea 
which ravaged parts of Germany in the last century. Give two or three grains 
of each every second or third hour; and increase or diminish each of the ingre- 
dients according to circumstances, increasing the Dover's powder where the 
indication is to remove pain and irritation, and increasing the rhubarb where 
you wish to produce a laxative effect. This combination forms a remedy of 
decided value in enteric inflammations: it has been much used in such cases 
by Dr. Cheyne, and 1 have repeatedly employed it in the Meath Hospital with 
marked advantage. You are also to bear in mind that though the principle of 
treatment in this disease is to remove its cause and put a stop to the purging, 
still you are in no case authorized to give it a sudden check by astringents in 
the early period. I gave the reasons for this at my last lecture,, and showed 
that it was based upon a general law of the economy. If an organ in a state of 
inflammation pours out an increased quantity of secretion, it is the mode in which 
nature attempts to give relief, and if you suddenly arrest this secretion, the proha- 
hility is that you will excite more inflammation in that organ, or cause a metastasis 
in other parts. This is particularly the case if inflammatory fever exists. You 
must also attend to your patient's diet. Your object here is to support him on 
such a diet as will require but little digestive power, and will not produce large 
collections of fsecal matter in the bowels. Jellies, arrow-root, chicken broth, 
and mild farinaceous food are the only thiKgs that can be used v/ith safety, until 
the intestinal irritation has subsided. 

By pursuing this plan of treatment with steadiness and decision, you gene- 
rally succeed in cutting short the disease. In some cases the diarrhaea will run 
on to the chronic stage, just like the gleet which follows gonorrhoea; and this 
is to be looked upon as the apyrexial period, in which antiphlogistic remedies 
are no longer admissible, and when you may employ stimulants and astringents 
with effect. The best way to manage this form of the disease, is to make your 
patient use warm clothing, or even temperature, and mild nutritious diet; to 
prescribe the vegetable and astringent tonics, the hip-bath, and the occasional 
use of mild laxatives, followed by an opiate. In this way, after some time, the 
disease generally goes off, and the patient recovers his strength. But it may 
happen that this gleety discharge will continue unabated; it is running the pa- 
tient down, and he wants some decided remedy to check it. Now the remedies 
which appear to have the greatest power in stopping this discharge, are the 
metallic astringents, and the turpentines and balsams, combined with some of 
the preparations of opium. It is a curious and interesting matter to consider 
how these remedies act. They are a class of medicines which exercise an ex- 
traordinary influence over discharges from mucous surfaces, in a way we do not 
understand, but the effect is to arrest these discharges. In a case of ophthal- 
mia, accompanied by copious secretion from the conjunctiva, ^or in a case of 
chronic gonorrhoea, we know there is nothing more beneficial than metallic as- 
tringents and balsams; and we are also aware of the great value which turpen- 
tine and balsam copaiba possess in checking the increased expectoration of a 
chronic bronchitis. In diarrhoea, also, they have the same power; they check 
inordinate secretion, and remove the morbid condition of the mucous membrane 
on which it depends, by some effect produced on the surface of that membrane, 
but in what manner this is accomphshed we know not. In severe cases of this 
gleety discharge, one of the most certain remedies we can employ is acetate of 
lead. You will seldom have occasion to use this or any of the other remedies 
alluded to, in the case of a healthy person, because the disease will seldom pass 
into this second or gleety stage, but if it should, and that it is running down the 
patient, it behoves you to check it as soon as possible, consistent with safety. 
Give then the acetate of lead in free and repeated doses, and it is singular to 
mark what quantities of it patients under such circumstances will bear without 
any bad consequence ensuing. Hitherto many persons have been afraid to em- 



236 QUARTERLY PERISCOPE. 

ploy it in large quantities, from fear of producing painters* colic; but at present 
it is known that this disease is to be attributed to the absorption of the carbo- 
nate of lead in almost every instance, and that the acetate is comparatively 
harmless. On this point I can mention one interesting fact, namely, that I have 
been in the habit of using it constantly, and in considerable doses, for the last 
six years, and I cannot bring to my recollection one single instance of colic pro- 
duced by it. One patient in particular, who was under my care, took it in very 
considerable doses for six weeks, without any apparent injury. The only cases, 
in which I have seen the acetate of lead act as a poison, were those in which it 
had been used as an external application. Whether it be that this remedy is more 
pernicious when employed after the endermic mode, or whether, when applied 
to the skin, it attracts carbonic acid from the air and is converted into a car- 
bonate, I do not know, but of this I am certain, that where bad effects have fol- 
lowed the employment of the acetate of lead, they have been brought on by 
its external use. I generally use this remedy in the form of pill, prescribing 
two grains of the acetate of lead and a quarter of a grain of opium, three times 
a-day. With the same intention you may employ the turpentines and balsams, 
which have a powerful effect in checking mucous discharges. Dr. Pemberton, 
in his work on Abdominal Diseases, speaks very highly of the efficacy of bal- 
sam copaiba; and I have seen many cases where turpentine has had a great effi- 
cacy in arresting chronic diarrhoea. You will see, in the works on materia me- 
dica, some other remedies which you can employ with benefit in such cases, but 
I may mention one which is not generally known, — the alkali of the nux vomi- 
ca. Strychnine was first used in checking mucous discharges by a German 
physician, and afterwards by Dr. Graves in this city. The cases, in which it 
proves most successful, are those in which there is a mere gleety discharge, a 
copious secretion from the mucous surface without any inflammatory action 
whatever, or if there be, where it is so low as not to produce the least feverish 
excitement or pain. Cases of this kind, in which strychnine has been eminently 
successful, have been published by Dr. Graves. Among others is that of a gen- 
tleman, who had sudden calls, so that he often had not time to reach the close- 
stool. He passed a quantity of thin jelly-like substance, and then experienced 
a transient relief until another attack came on. This case was cured by the 
use of strychnine, one-twelfth of a grain, three times a-day, made into pills with 
crumb of bread or aromatic confection. 

I may mention here, that, in treating gleety diarrhcea in this way, one thing 
should be always borne in mind, — it is always dangerous to check any copious 
secretion suddenly, and the danger consists in the liability to metastasis or new 
inflammation. Never forget this. What generally happens is, that the pa- 
tient's belly begins to swell, and you have ascites rapidly formed. Now, I have 
never seen a case do well in which this kind of ascites came on after the sudden 
checking of a diarrhoea, the patients all died. Another consequence is the 
rapid supervention of pulmonic inflammation, and here the disease is almost as 
bad as in the bowels. You will ask how this unfavourable termination may be 
avoided. The best mode is, while you are arresting the discharge from the bowels, 
to promote a determination to the surface. While you are using opiates, and 
stimulants, and astringents, employ general warm bathing, or the hip bath, 
dr^ss the patient in flannel, and use mild diaphoretics every night. You will 
also do right in blistering the belly occasionally. In this way you will succeed 
in curing the worst cases of this chronic flux, without exposing your patient to 
the risk of new inflammation, or translation of disease to other organs. 

One of the most common forms of diarrhosa is the purging which occurs in 
cases of phthisis; a physician will be called to treat this as often as any other, 
and it is of importance that you should have correct ideas with respect to its 
pathology and treatment. The ordinary opinion is, that this kind of diarrhcea is 
one of the results of hectic fever, and many practitioners, in treating the purg- 
ing of consumptive patients, overlook the actual condition of the intestine, and 
only take into consideration the state of the whole constitution, of the hectia 



Practice of Medicine. 237 

state of which, the diarrhoea is looked upon as one of the symptoms. The con- 
sequence of this is, that they do not proceed on the same principles in the 
treatment of this as of other similar affections of the intestinal canal. Now I 
would impress upon you, that you should always consider the diarrhoea of 
phthisis as depending in almost every instance on enteric inflammation. There 
is no fact ira medicine better established than this. Persons think it is the hec- 
tic which produces the purgation, but I believe the converse of this proposition 
is often much nearer the truth, and that the constant diarrhoea often produces 
and keeps up the hectic. If you examine the digestive tube of a patient who 
has died with symptoms of phthisical diarrhoea, you will commonly find exten- 
sive ulcerations in the colon, caecum, and ileum. In some cases of consump- 
tion, where the purging has been very severe, the amount of disease will often 
be found to be quite extraordinary; I have often seen the whole of the lower 
part of the tube one sheet of extensive ulceration. I find I have not brought 
up any specimens of the effects of phthisical diarrhoea from the museum, but 
will exhibit them at our next meeting. The preparations before us are those 
which are illustrative of dysentery, but they will convey to you a good idea of 
the state of the great intestine in the diarrhoea of consumption, for the effects 
are nearly the same. Observe now, gentlemen, the importance of this fact, 
and recollect that in treating every case of consumption with diarrhoea you will 
have constantly to bear in mind this enteric complication. Eecollect, also, that 
one of the best means of stopping it, when all other remedies have failed, is a 
blister applied over the abdomen. If the purging depended on hectic this 
would not be the case. I could bring forv.7ard several cases in which every 
thing had been tried without success, when a blister was applied to the belly, 
and from the time it rose, the patients ceased to be troubled with diarrhoea, and 
continued so up to the period of death. I do not mean that you should in these 
cases proceed to attack the enteritis with the same vigour as you would a similar 
disease in the healthy subject. Generally speaking, I believe this form of en- 
teritis to be incurable, but it is of importance that you should be aware of this 
enteric complication in phthisis, and when you are called in to treat such a case, 
3'ou should carefully avoid prescribing any thing calculated to add to the exist- 
ing irritation. 

Before I quit this subject, I wish to make one remark by the way of caution. 
It not unfrequently happens that a person, labouring under chronic diarrhoea, 
comes to consult a medical practitioner, and tells him that he has been suffer- 
ing from this complaint for months, that he has eight or nine discharges by 
stool in the day, and that he has been under the care of five or six doctors in 
succession without any benefit. Well, you are determined to have your trial 
too, and you commence operations by putting him on full doses of acetate of 
lead. After a week or a fortnight he comes back and tells you he is not a bit 
the better. You then try turpentine or balsam copaiba — no use. Nitrate of 
silver — the same result. The man gets tired of you in turn, and perhaps goes 
to a surgeon to ask his advice. The surgeon examines the rectum carefully, 
and finds, at a short distance from the anus, an ulcer, which he immediately 
touches with a strong solution of the nitrate of silver. The ulcer begins to heal, 
and accordingly as it heals, the irritation of gut ceases, and the diarrhoea goes 
off. The surgeon is extolled to the skies, and the doctors disgraced for ever in 
the opinion of the patient. Now this is not an uncommon case. I have seen 
several instances of it, and I must tell you I was once mistaken in this way my- 
self. These ulcers are situated close to the verge of the anus, they occur 
chiefly in persons of broken-down constitution, and those who have taken a 
great deal of mercury. They produce irritation in the colon, tenesmus, griping, 
frequent discharges by stool, and, most commonly during the straining, a little 
blood is passed. During the course of last summer, I treated a soldier for this 
affection, who had been discharged from the East India Company's service, (as 
was stated in his discharge;) for incurable dysentery. I examined the rectum, 
and finding some ulcers close to the anus, had them touched with the nitrate of 



238 QUARTERLY PERISCOPE. 

silver. Under this treatment a rapid amendment took place; and in the space 
of three weeks the man was discharg-ed quite cured. Now, are you to make 
this examination in every case? 1 beUeve you will actrig^htly in doing so in every 
case of chronic diarrhoea in the male, but the examination is absolutely neces- 
sary in all cases under the following" circumstances: first, when the diarrhoea has 
been of long- standing-; secondly, when it has resisted a g-reat variety of treat- 
ment; thirdly, when it is combined with tenesmus and a desire of sitting- on the 
night-chair after a stool has been passed, showing irritability of the lower part 
of the great intestine; and lastly, when the patient's health does not appear to 
be so much affected as it naturally should be, where there was long-continued 
disease of a large portion of the great intestine. A patient will come to consult 
you, who will inform you that he has had eight or ten alvine evacuations every 
day for the last six months, and yet he eats heartily and looks quite well. Un- 
der these circumstances, the cause of the diarrhoea will generally be found to 
be ulceration of limited extent low down the tube, and capable of being quickly 
and effectually removed by a strong solution of the nitrate of silver. I shall 
recapitulate all the circumstances under which an examination is indispensable; 
where the symptoms have been persistent, have resisted a variety of treatment, 
are accompanied by tenesmus, and where the injury done to the general health 
is not in proportion to the duration of the disease. 1 may mention here, that a 
medical friend of mine has communicated to me the particulars of another case 
of this form of diarrhoea in a soldier who was invalided on this account, and 
who experienced sudden and permanent relief from the application of nitrate 
of silver to some ulcerated spots which were discovered near the termination of 
the rectum.— Ibid. March Ist, 1834. 

47. Inhalations of Chlorine in Phthisis. — M. Toulmotjche, of Rhelms, has em- 
ployed the chlorine inhalations in eighty phthisical patients, all of whom had 
pectoriloquism, and all of whom died. He has seen but one patient with bron- 
chophony cured, and this individual, who died eight months subsequently of 
another disease, it was found had only dilatation of the bronchi. — Bev. Med. 
Jlvril, 1834. 

48. Tartar Emetic in Frictions as a Means of Producing liesoluiion. — M. 
YvAN announced to the Academy of Medicine at their meeting on the 4th of 
February last, that he has found an ointment, composed of a drachm of tartar 
emetic and an ounce of lard, to produce the resolution of indolent and harden- 
ed glandular tumours which had resisted the preparations of iodine and the 
other usual remedies. — Annales de la Med. Phys. February, 1834. 

49. Pruritus. — Dr. CARROK-Dix-ViiLAaDS has employed with advantage lo- 
tions of the distilled water of the Prunus laura-cerasus in pruritus of the genital 
organs of women, which has resisted many other remedies. — Bull. G6n. de The- 
rap. Feb. 1834. 

50. Swelled Breasts. — M. Ranque, of Orleans, some time since, (See Vol. V. 
p. 214, of this Journal,) recommended the laurel water as a means of suspend- 
ing the secretion of milk; M. Carhon-bu-Villauds, in a memoir in the Bulle- 
tin General de Therapeutique^ confirms its efficacy, and states that to produce 
that effect it is sufficient to apply fomentations of equal parts of distilled cherry- 
laurel water and of the oil of sweet almonds well mixed, to the breasts. Dr. 
Caffe states, {Journal Hebdom., Vol. II. p. 23,) that he has also had opportuni- 
ties of appreciating the employment of similar embrocations in cases of mam- 
mary swellings with secretion of milk and acute pain, resulting from too rapid 
weaning, and when salts and other laxatives of various kinds had not afforded any 
relief. In one case in which there was very acute pain, with swelhng of the right 
breast, the last mentioned physician ordered the application of a piece of fine 
linen wet with the following liquid :—R. Aq. distil, prun. laur.ceras. §j.; Ether. 



Practice of Medicine. 239 

sulph. 9J-^ Exlr. g-uTD. opii, gr. iij. M. The swelling and pain disappeared, as 
it were, spontaneously. 

51. Incurable Neuralgia of the Ulnar Nerve. — Professor Viviakt, not long 
after his recovery from an attack of rheumatic sciatica, began to experience 
slight pricking and formication, preceded by a feeling of an aura in the left 
forearm, along the line of the ulna, the ulnar side of the carpus, and in the 
little and ring fingers. These sensations, at first trifling and transitory, be- 
came more severe, and fixed in the palmar superficies of the wrist, on the side 
of the pisiform bone, and extending thence along the palm to the two fingers^ 
but never retrograding. The paroxysms of pains increased in violence — some- 
times short, but dreadfully agonizing, each throb shooting along with the 
rapidity of hghtning; at other times they were more protracted. The pulse at 
the part was never affected, and the general health of the Professor was per- 
fectly good. During the space of three years, every remedy that could be de- 
vised was tried, but in vain. He then consulted the celebrated Scarpa, who 
gave it as his opinion, that the nerve was probably not diseased higher up thari 
the seat of the pain, as he found that firm compression on the carpus, during a 
paroxysm, very considerably mitigated the pain. He, therefore, recommended 
the division of the nerve in the forearm. 

An incision was made, beginning about an inch above the pisiform bone, 
and carried upwards, along the side of the tendon of the ulnaris internus; and, 
on dissecting between this tendon and that of the pulmaris longus, the ulnar 
artery and its accompanying nerve were easily exposed. About half an inch of 
the nerve was excised; the little and ring fingers immediately lost all feeling 
and mobility. 

The hopes of the patient and surgeon were soon blighted. During the night 
after the operation, a paroxysm, quite as severe as any preceding one, was ex- 
perienced; the pain seemed to commence at the upper angle of the wound^ 
and darted to the extremities of the two fingers. The condition of the patient 
•was, therefore, not at all bettered by the operation; indeed, the fits of suffering 
became more lengthened and excruciating; on one occasion, the pain lasted 
unceasingly for thirty-six hours. The two fingers were all this time quite pal- 
sied, and generally half bent upon the palm of the hand. 

Four years after this date. Professor Viviani wrote to Scarpa, acquainting 
him that, since the operation had been performed, (1827,) his sufferings had 
become more and more intense, and that they had defied every attempt, even 
to relieve them for a time. — Med. Chirurg. Rev. and Jinnali Universali di Med. 

52. Mercurial Inunctions in the Treatment of Paronychia.— M. Serre D'Alais 
highly extols the use of mercurial frictions in paronychia. The editor of the 
Bulletin Therapeutique, who has tried this plan of treating the disease, says 
that he has never seen more marvellous cures than those which he has ob- 
tained. In a few hours all pain is calmed, and the progress of the most violent 
panaris arrested. This has constantly occurred in all the cases the editor has 
treated, (five,) and lie considers this method as the most prompt, certain, and 
efficacious that we possess in this painful and sometimes serious disease. The 
finger is rubbed every quarter of an hour with some of the mercurial ointment.. 
After each friction the finger should be enveloped in a linen rag, spread with 
the ointment. One or two drachms are said to be almost always sufficient for 
the complete cure. — Trans. Med. Sept. 1833. 

53. Soot in Cutaneous Diseases. — M. Blaxd extols the efficacy of a decoction 
of soot, or a mixture of this substance with lard, in obstinate tetters, different 
species of tinea, especially tinea favosa, malignant ulcers, &.c. This formulae 
are as follows: — R. Aq. purse, ibj.; Fuligo, manip. ij. Boil for half an hour, 
express the liquor, and use it in tinea, as a lotion three or four times a day, 
first removing the crusts by means of poultices. In ulcers, lint is to be wet 



240 QUARTERLY PERISCOPE. 

with it and applied to the part; and in obstinate fistulae kept up by caries of the 
bones, it is to be employed by injection. R. Axung-. §ij.; Fuligo, q. s.; to be 
mixed in small portions until the ointment becomes of a dark brown.' — Juurn. 
des Connais. Med. Chirurg. May, 1834. 

54. On the Use of the Phosphoric Acid in the last Stage of Croup. — M. August 
Boxer, in an interesting- memoir in the Gazette Medicate for 15th of February 
last, sugg-ests the employment of the phosphoric acid in the last stages of 
croup. He states, that the above named acid, when applied to a mucous 
membrane, produces an acute, but very temporary inflammation, and that it 
completely dissolves albumen and fibrin. He thinks it preferable to the nitrate 
of silver and hydrochloric acid, as it possesses equally with these, the property 
of exciting a new inflammation, which replaces or modifies the first, and it has 
this advantage, that while the latter remedies increase the density of the false 
membrane the first dissolves it. He says that he has taken the false membrane 
from the trachea of an infant who had died of croup, placed it in the phospho- 
ric acid, and that it was completely dissolved. 

It is necessary that the phosphoric acid be entirely free from the nitric acid 
employed in its formation, since, if it is not, it partakes of the inconvenience of 
the other acids, that of coag-ulating- albumen. 

55. Blgonia Catalpa in Asthma. — Encouraged by the success which Koempfer 
and Tluimber niet with in the employment of the Bigonia catalpa in different 
asthmatic aflfections, some of the medical men in Naples have made trial of the 
plant, and have obtained results equally satisfactory. By administering in the 
movnnig a decoction made of the seeds and part of three or four of the husks 
of this plant, in twelve ounces of water, boiled down to six, and a similar decoc- 
tion in the evening, the fit of asthma is much diminished in violence. The fol- 
lowing is the result of an analysis of this plant made by Signor Grasso: about 
ten parts of an oily substance; malic acid partly combined with lime, partly in 
a free state; and lastly, an uncrystallizable sweet TpY\wc\^\e. — Lund. Med. and 
h'urg. Journ. from Bull, delle Sc. Med. Bologne. 

56. On the Employment of Chloride of Lim,e and Soda in some Affections of the 
Mouth, common in Children. — Dr. Constant states that wounds of the mouth, 
vilceration of the tonsils, &.c, assume a favourable appearance after the applica- 
tion of chloride of soda or lime, and speedily heal. 

Dr. BoNNEAU employs in conjunction with the above, a gargle composed of 
decoction of barley, 3 oz.; conserve of roses, 1 oz.; chloruret of soda, pij* to 

M. GuERSENT, in gangrene of the mouth, prescribes a gargle composed of 
decoction of cinchona, 5iij. ; syrup of orange-peel, ^j. ; chloruret of soda, ^j. M. 

M. AngeIiOt, in ulcers of the gums, uses the following wash. Chloruret of 
lime, 15 to 30 grs. ; mucilage of gum Arabic, ^j. ; syrup of oiange-peel, ^ss. To 
be applied to the ulcers by means of some lint. — Bull, de Therupeutique. 

57. On the Employment of Chloruret of Lime in Itch. — Dr. Hospital uses ge- 
nerally in the treatment of this disease from ten to twelve ounces of the follow- 
ing ointment: — R. Lac. sulph. ^iss. 5 chlorur. calcis, pulv. subtil. §ij.; axung. 
Svj. M. 

^8. On the External Use of Croton Oil. — This valuable drug was first made 
known to the profession by Dr. Connwell, in 1820, and subsequently its thera- 
peutic effects were investigated by MM. Recamier, Bally, and Majendie; their 
researches were, however, limited to its internal exhibition, and it was not 
until 1831 and 1832 that its great value, as a counter-irritant to the skin, was 
clearly proved by Professor Andral. 

External Use. With one or two fingers or, if we choose, with a dossil of 



•J 



J 



Practice of Medicine. 241 

lint, wetted with the oil, we continue rubbing the skin for the space of about ten 
minutes. This operation should never be entrusted to the patient hinriself — in 
two cases at the Hopital de la Pitie, we observed violent ophthalmia and in- 
flammation of the penis and scrotum induced, no doubt in consequence of the 
mere inadvertently carrying" their fingers to their eyes and genital organs. 

The eruption which is brought ovit by the external use of the croton oil, may 
be divided into five stages: — 1, Rubefaction of the skin — 2, Formation of vesi- 
cles — 3, Conversion of the vesicles into pustules — 4, Desiccation of the pus- 
tules — 5, Desquamation and falling off of the crusts. 

These different periods or stages are not uniformly to be observed; they are 
most conspicuous when the friction has been made with ten or twelve drops of 
the oil, on a part of the skin where there is much subjacent ceUular tissue. 
The patient at first experiences a tingling u'armth, which is quickly followed 
by a considerable redness, extending an inch or so beyond the sphere of the 
rubbing. These appearances are generally noticed within seven or eight hours, 
sometimes in one or two, at other times not for ten or tv/elve hours; the differ- 
ences of time required depending, no doubt, on the delicacy of the skin. In 
from fourteen to twenty-six hours, myriads of small, close-set vesicles make 
their appearance upon the inflamed skin. Occasionally, a few of the vesicles 
become greatly magnified, forming true phlyctense, filled with a turbid lymph, 
which speedily change into a purulent matter. In twelve out of thirty-one 
cases reported by our author, the vesicles passed to desquamation without un- 
dergoing the suppurative process. 

The usual period at which the serum becomes puriform, is from thirty-six to 
fifty-four hours after the application of the oil. In one or two days subse- 
quently, the pus begins to exude, and forms grayish crusts over the pustules, 
and the desquamation is generally over by the eighth or ninth day. If the cro- 
ton oil is rubbed upon any part which has been recently vesicated, the eruption 
is, as we might expect, more speedy and abundant. 

In six cases it was tried whether the rubbing in of the croton oil, mixed with 
an equal quantity, or rather more, of that of almond oil, over the arch of the 
colon, would produce any purgative effects;— an eruption, which reached the 
second stage, was brought out, but the action of the bowels was not affected. 
Similar results were obtained when the pure oil, to the amount of twenty drops, 
■was rubbed round the umbilicus. Dr. Kayer states that he has repeatedly in- 
duced free action of the bowels by putting two or three drops of the oil upon 
a surface denuded of its epidermis by a blister. We have not repeated this ex- 
periment. 

Therapeutic Effects. The diseases in which the external use of this remedy 
has been employed with most advantage, are chronic rheumatism, arthritic 
pains, pleurodynia, paralysis, stomatitis, laryngitis, and chronic gastritis. 

Case I. — Sciatica. A man, aged 48, was admitted into the Hopital de la 
Pitie on the 6th December, 1831. For five months preceding he had suffered 
severely from pain, beginning in his right hip, and extending down the back 
of the limb, along the course of the sciatic nerve to the outside of the leg. For 
two months and a half he was obliged to keep the house, and, upon then 
attempting to resume his work, the pain returned with all its former intensity. 
He attributed his complaints to exposure to wet and cold. The only treatment 
which had been followed before his admission was blistering the limb; but he 
liad derived no benefit. When examined in the hospital, the pain was found 
to be increased by pressure, and by the heat of the bed; he complained of head- 
ache, but in other respects his general health was not amiss. Eight drops of 
croton oil were ordered to be rubbed in over the origin of the sciatic nerve. 
This produced considerable itching and redness, but no vesicles; and the pain 
being not relieved, eighteen drops of the oil were rubbed along the whole course 
of the affected nerve. Next morning the outer side of the leg was much red- 
dened, and vesicles had formed over the trochanters. On the 11th, ten drops 
more were rubbed in between the trochanters.— 12th. The eruption con- 

No. XXIX.— November, 1834. 21 



242 QUARTERLY PERISCOPE. 

siderable — some larg-e papulae had appeared over the fibula. The neuralgic 
pain almost gone — only the heat and itchiness of the eruption are troublesome. 
He left the hospital in a few days quite well. 

Case II. — Sciatica. A man, aged 50, entered the La Pitie Hospital in De- 
cember, 1831, suffering' from sciatica of six weeks' standing*. Twelve drops of 
croton oil were well rubbed in between the trochanters, along- the outside of 
the thigh, to the lower third of the leg; a copious eruption was induced, and 
already, upon the second day, the patient felt relieved. In six days more he 
was considered cured, and left the hospital, quite delighted v/ith the rapidity 
of his cure. 

He had experienced two severe attacks before — once in 1812, when he was 
treated in the Hotel-Dieu, by M. Recamier, with the essence of turpentine — at 
that time he was six weeks in the hospital; and again, two years ago, after ex- 
posure to wet and fatigue, he was admitted into the Hopital de la Charite, un- 
der the care of M. Fouquier, who employed bhsters and friction, with anodyne 
balsam. He was cured then in three weeks. 

Case lit. — Sciatica. A stout, plethoric man, forty-five years of age, had for 
about a month felt general indisposition, frequently-returning shiverings, and 
neuralgic pain of the left extremity. He was taken into the La Charite Hospital, 
and there treated by M. Rayer with repeated venesection, the application of 
fifty leeches to the hip, and forty more to the back of the thigh. The essence 
of turpentine was administered inwardly in frequent doses; and besides all this 
the vapour-bath was used fourteen times. This treatment was continued for 
three weeks, and as little benefit had been obtained, the patient left the hos- 
pital, and a few days subsequently entered the La Pitie. At that time the pain 
extended from the ischium down the ankle-joint, and it was increased by walk- 
ing, and by the heat of the bed: the lower part of the leg was annoyed by a 
feeling of formication. The digestive organs were in good order. Fifteen 
drops of croton oil were rubbed in over the origin of the sciatic nerve. On the 
following day, twenty drops more were rubbed over the tract of the affected 
nerve; a vesicular eruption made its appearance, and the neuralgic pain was 
already diminished. On the 29th, (third day,) twenty drops were again order- 
ed. 30th. The eruption is very abundant — the vesicles have changed into 
large pustules. The patient complains only of the itching; the pain is gone. 
He remained a few days longer in the hospital, until the crusts separated; and, 
on the 12th day after his admission, he was discharged cured. 

A case of chronic rheumatism of the shoulder-joint, supervening on typhus 
fever, is given, in which general and local bleeding, blisters, &c. had been 
fruitlessly used for the space of six weeks. The friction with a few drops of 
croton oil was employed twice; and on the third day the patient could move 
his arm — although not entirely cured, he was very much relieved when he left 
the hospital. 

Case IV. — Anaesthesia, or Paralysis of Feeling. Pierre Dumas was admitted 
into the Hopital de la Pitie on the 9th November, 1831. Seven months before 
he had an attack of erysipelas of the face, and the inflammation had extended 
down the left side of the neck. Three weeks after his recovery from this ill- 
ness, he was suddenly seized with dimness of sight and stunning noises in his 
ear; these symptoms w'ere not constant, but came and went, returning every 
second or third day. 

This state of things lasted for about two months, during which nothing had 
been done in the way of medical treatment; and then there supervened a ge- 
neral numbness of the whole left side of the face, and the sight of the left eye 
became aff'ected at the same time— the left nostril lost the sense of smell, and 
the left side of the mouth its sense of taste. When he was shaving, he felt as 
if some foreign body was placed upon his cheek; and, in chewing, the food 
seemed like earth in his mouth. He complained of a very severe frontal cepha- 
lalgia — the tongue was loaded, the abdomen soft, the bowels rather relaxed, 
pulse 90, breathing not affected. He was ordered to be largely bled from the 



Ophthalmology. 243 

arm — to use a mustard-bath to the feet at night, and to be put on a light emol- 
lient diet. 

V)th. No relief; half a drop of croton oil in two pills at bed-time. 

Wth. Twenty liquid stools from the pills; head-ache much better? paralysis 
not affected. Eight drops of the oil to be rubbed upon the left cheek and side 
of the neck. 

On the following day the skin was well reddened, and a large crop of con- 
fluent vesicles had made their appearance; to our great surprise he had already 
recovered his sight, taste, smell, and feeling. The fifth period of the eruption, 
or that of desquamation, was not over until the thirteenth day. He did not 
leave the hospital till the 12th December, having had a threatening of a relapse 
of the numbness in a slight degree; but this was checked by a bleeding from 
the foot. 

Case V. — Angina Laryngea — Aphonia. An itinerant singer of the streets of 
Paris, presented, upon his admission, the following symptoms; a frequent, dry, 
and harsh cough; pain over the larynx, increased by swallowing; breathing sibi- 
lant; voice ahTiost entirely gone, so that he could not make himself understood. 
Upon examining his throat, the velum and its pillars were observed red and 
swollen. Venesection, a sinipised foot-bath, and emollient drinks ordered. 
The following day he was much better; the general symptoms were relieved; 
but the aphonia was as complete as before. Ten drops of croton oil to be rubbed 
on the front of the neck. In twenty four hours there was a copious confluent 
eruption, the voice was regained, and the deglutition more easy. He left the 
hospital three days afterwards quite cured. 

Case VI. — Diptherite, or Stomatitis pseudo-membranacea. An old soldier, up- 
wards of sixty years of age, exhibited a specimen of this disease to our notice 
in the Hopital de la Pitie. It had already existed for eight days, and had made 
considerable progress; the inside of the mouth and the surface of the tongue 
being covered every here and there with small oblong crusts, or laminae of a 
g'rayish-white colour, set upon red, inflamed, and swollen bases; the submax- 
illary glands were painful and enlarged; the breath excessively fcEtid, the lips 
swelled and of a purple hue; and the deglutition very difficult. Sixty leeches 
had been applied at two diflTerent times behind the jaws; and poultices and a 
multitude of gargles had been used without much good for the poor patient, 
who could scarcely articulate a word. Eight drops of croton oil v/ere ordered 
to be rubbed in upon the sides of the neck. On the morrow a copious eruption 
of vesicles had appeared, and considerable relief was already experienced. 
From this period the disease appeared to have undergone a favourable change, 
and in fifteen days more, under the use of acid gargles and of poultices, it was 
altogether removed. — Archives Gen. Aug. 1833, and 3Ied. Chir. Rev. July, 1834. 



OPHTHALMOLOGY. 

59. On the Use of Soot in Diseases of the Eyes. — The Gazette Medicale, for Ja- 
nuary, 1831, contains some facts collected by M. Cakron-du-Vixlarbs favour- 
able to the use of soot in diseases of the eyes. M. Baudelocque, physician to 
the Hopital des Enfans, has also extolled this article in scrofulous ophthalmia. 
The following is the formula of the first named practitioner: — Soot, ^ij.; dis- 
solve in boiling water, filter and evaporate to dryness. The residue, which is 
very brilliant, is to be dissolved in boiling very strong white vinegar, with the ad- 
dition of 24 grs. extract of roses to ,^xij. of liquid. Some drops of this solution 
in a glass of water form a good resolvent collyrium. M. Carron-du-Villards re- 
commends granulations of the cornea to be touched with a very fine brush wet 
with the following mixture — Take of Opium, gij.; Cloves, gj.; Washed soot, 
,:5iv.; Cinnamon water, ,^viij.; Alcohol, ^iv. To be digested for six days in a 
warm place, and then expressed and filtered. — Bulletin General de Therapeu- 
iique, March, 1834. 



244 QUARTERLY PERISCOPE. 

60. Of the Capsulo- Lenticular JRedination, or New Method of Depressing Ca- 
taract with a New Needle. By M. BEHGKOjf, Interne of the Hospital Saint An- 
toine, and Doctor of Medicine. — The frequency of secondary cataract is not 
questioned; a great service would therefore be rendered to science, by point- 
ing" out a method of operating calculated to prevent this unfortunate accident. 
This was the principal end wliich I proposed to myself; but I was also desirous 
of finding a method, which by its excellence and facility would bring to a close 
the interminable debate concerning extraction and depression. With this view 
I found it necessary, 1 will not say to invent a new instrument, but to modify 
considei-ably one of those employed by the partisans of depression. My task 
will doubtless seem very difficult to perform; consequently I shall esteem my- 
self fortunate if I merely approach the end which I desire to obtain, since my 
efforts will then not have proved entirely fruitless. 

To describe the instrument with which I operate, and the method which I 
employ, to point out the advantages which it seems to possess over those hitherto 
made use of, and to declare fiankly the inconveniences to which it may be ex- 
posed, is the course which I intend to pursue in the following dissertation. The 
needle which [ employ, and to which I give the name of reclinator, is of the 
same length as those commonly employed; it is composed of a blade having two 
surfaces, one convex, anterior, (with respect to the person operated upon,) or 
iridian; the other concave, posterior, or crystalline, (for I give notice that I 
shall employ these terms indiscriminately.) The convexity of the anterior or 
iridian surface, is formed by the reiinion of two planes which form a rounded 
angle along the median line. The posterior surface is concave only in its lon- 
gitudinal diameter, which is four lines; transversely it is perfectly flat, and dif- 
fers in this respect considerably from the needle of Scarpa, which presents a 
bold angle or ridge in this direction; and from that of M. Dupuytren, which 
also presents a projection in the same direction, less pronounced however than 
in the needle of the Pavian professor. The transverse diameter of this surface 
is a line and a half; its concavity is such as to correspond exactly with the con- 
vexity of the crystalline lens. The point of the needle, instead of tapering off 
very finely, like that of M. Dupuytren, on the contrary terminates rather ab- 
ruptly. The general form of this little blade is that of an oval, a little prolong- 
ed, and curved upon itself The two edges may be distinguished into superior 
and inferior; the former should be a complete cutting edge throughout its length; 
the latter for the first half only, starting from the point; this last disposition is 
made with a view to prevent a lesion of the iris, as will be hereafter observed. 
The two edges of the blade terminate towards the handle in a narrow portion 
called the neck, beyond which is found a bluish mark two lines in length, which 
is of great advantage in making known to what extent the reclinator may be 
plunged in the ocular globe. It is the same object which Graefe wished to at- 
tain, by adding to his needle a little transverse bar; but is not the defect of such 
an expedient immediately obvious? The metalhc stem which supports the ex- 
tremity of the needle is an inch or an inch and a quarter in length. The handle 
into which the stem is introduced is of the length of the common needles; it has 
four surfaces or planes; one corresponds with the crystalline surfiice; it is tva.- 
versed throughout its whole length by two little parallel lines, which are black 
if the handle be ivory, and white if it be made of ebony. Upon the plane which 
corresponds with the iridian face of the needle, are three rounded m.arks, equally 
separated from each other; the two planes of the handle which corresponds 
with the edges of the blade, have no particular mark, and may thus be easily 
distinguished. 

I have already said that, in my process, it was my aim to remove as com- 
pletely as possible, not only the crystalline in totality, but also the entire cap- 
sule, and to repel them unbroken, into a part of the eye, where they could no 
longer prove an obstruction to vision. If [ attain this end, it must be ac- 
knowledged that I will have found the solution of a very difficult problem, and 
one which has been proposed by the illustrious Scarpa in his work upon the 



I 



Ophthalmology. 245 

Diseases of the Eye. He thus expresses himself, (5th edit.) " that which most 
generally opposes itself to the complete success of the operation for cataract, 
whatever method is employed, is not the crystalline lens, notwithstanding- its 
density, more or less considerable, but the capsule of the affected lens, and 
more particularly the anterior convexity of the capsule. It would be very de- 
sirable to find an easy and efficacious method which would permit the surgeon, 
in the various modes of operating for cataract, to separate accurately, at the 
same time with the opaque crystalline, the entire capsule of the lens from the 
ciliary zone to which it is attached, as is sometimes accomplished by a happy 
and unforeseen accident." 

It is precisely this last indication which I wish to fulfil by my process. I am 
well aware that certain partisans of depression aim at the same end; we shall 
soon see in what manner they endeavoured to attain it, and above all whether 
they have succeeded: I will afterwards expose my ideas with regard to this 
matter; but in order that I may be better understood, it is indispensable to 
recall in a few words, the manner in which the crystalline lens and its membrane 
are fixed in the eye; and that I may not be accused of partiality or exaggeration 
in the description, I will copy literally an anatomist who is an honour to the pre- 
sent school, and whose authority no one will question, viz. M. Jules Cloquet, 
who says,* "from the interval of the ciliary processes, and from the surface 
even of their anterior extremities, are detached innumerable small rounded 
filaments, transparent, united in bundles, which I think I was the first to 
point out, and which are directed towards the circumference of the lens, in 
order to attach themselves to its membrane, which they thus fix in a solid 
manner. These filaments expand, some upon the anterior surface of the cap- 
sule, the other upon its posterior face, but do not extend more than a line 
beyond its circumference. It is impossible to see them on account of their ex- 
treme tenuity, and their transparency, without having macerated the eye, 
(opened,) in a solution of gallate of iron; it is then only that their disposition 
can be studied. They form, as it were, so many little tendons, which keep the 
capsule and the lens in place. Much more visible in certain animals than in man, 
those filaments have been improperly regarded as the anterior lamina of the 
hyaloid membrane, to which they adhere posteriorly alone, at the point where 
they detach themselves from the ciliary circle. It is these which form the an- 
terior paries of the pretended canal of Petit." 

Method of Operating. — The patient having been properly prepared, and the 
pupil previously dilated by the extract of belladonna or of hyosciamus, he must 
be laid in a bed placed opposite a window, but so disposed that the light may 
fall a little obliquely upon the cornea. The head must be elevated by a bolster 
and two pillows; the arms placed under the bed-clothes will be easily retained 
by them. An assistant must stand behind the head of the bed, the head-piece 
of which should be but little raised; he must place one hand behind the neck 
of the patient, while with the other he raises the upper eyelid; by this means 
the head and the lid will be permanently fixed. The surgeon seated upon the 
side of the bed opposite to that of the eye to be operated upon, will find in the 
position of the patient, a point d'appui, the more convenient because it will be 
in his power to select it when he pleases. The eye of the patient being turned 
upwards and inwards, the needle must be held like a writing pen, with the 
right hand, (if the left eye is to be operated upon, et vice versa;) then the 
two last fingers resting upon the temple, and the needle directed transversely, 
so that its convex surface is superior; the surgeon must carry it two lines and a 
half behind the transparent cornea, and one line below the transverse diameter 
of the eye; by a quick movement he must then introduce the whole blade of 
the needle behind the lens, stopping however at the neck of the instrument, 
the advantage of which at this stage of the operation is easily comprehended. 
AH the precautions which I have just indicated must be taken, that the long 

• Manual of Anatomy. 

21* 



246 QUARTERLY PERISCOPE. 

ciliary artery may not be wounded. At the moment when the point of the 
needle touches the sclerotica, the extremity of the handle should be pretty 
low; but it is necessary to elevate it gradually, as the blade penetrates into the 
interior of the eye. 

Before proceeding- to the second stage of the operation, the handle of the 
needle is to be lightly turned in the fingers, so that the pointed surface from 
being superior becomes inferior. The needle occupies then the same position 
behind the lens which it is soon to occupy before that body. In order to ac- 
complish this second stag'e,the blade must be depressed by elevating the handle; 
the superior edge of which alone is cutting its whole extent, is to be gradually 
directed forward, and must be carried gently under the capsule; it will thus 
embrace all the inferior and half of the exterior ligaments; it is to be raised after- 
wards by passing it before the lens and its capsule. However transparent this 
latter may be, it will be always easy with a little attention to recognise whether 
the needle is before or within it. Let us suppose first the most fortunate case. 
The operator will cut all the internal ligaments of the capsule with the point 
of the blade, he will then carry the superior cutting edge against the superior 
ligaments, and the remaining half of the exterior ones; then the needle being 
brought behind the pupil, and in a direction somewhat oblique, he will proceed 
to the third and last stage, viz. the reclination of the lens and its capsule 
entire. To accomplish this, the lens must be thrown backwards, downwards, 
and a little outwards, by carrying the handle of the needle upwards and out- 
wards. This last stage of the operation is so easy, that the promptitude with 
which it is performed sometimes causes surprise. The crystalline must be 
maintained thus depressed some moments, in order that the vitreous humour 
may enclose it, and prevent it from rising again; to obtain greater security,-the 
handle may even be gently turned in the fingers, so that the pointed surface 
may become inferior, and the linear surface be placed above. 

It is apparent, that by this means it becomes very easy to bear upon the crys- 
talline with the convex surface of the needle, even when it might not be dis- 
tinguishable at the bottom of the eye, and there is no occasion to fear wound- 
ing the retina and the choroid coat with its point. I will suppose now, that in 
causing the needle to pass under the crystalline, and bringing it behind the iris, 
the operator penetrates between the lens and its capsule, instead of endeavour- 
ing to recommence this stage of the operation, which would not fail to irritate 
the iris, it is better to carry the point of the redinator through the capsule, by 
directing the extremity of the handle strongly tov/ards the temple of the pa- 
tient. Being seized thus, the crystallized is torn throughout the greatest part 
of its extent, and is carried away with the crystalline. When the needle is to 
be retracted from the ocular globe, its linear surface is turned upward, and 
the extremity of the handle must be gradually raised; on the contrary it must 
be depressed by degrees, when the pointed surface or face is in that direction. 
It will be seen, that hitherto in the operative procedure, I have considered 
merely the first variety of the first species of cataract, viz. that in which the 
crystalline is hard. I should examine now the case in which it is soft, or that 
in which it is diffluent; and finally, those in which it is capsular or mixed; but 
as my method is applicable to all of these cases, I shall say nothing particular 
concerning them, reserving to myself an occasion to say a word in relation to 
them, in speaking of the numerous advantages which I attribute to my reclinat- 
ing needle, (alguille-reclinateur.) 

The advantages of this method are, according to the author, the following: — 

1. The operation is easier than by the other methods. 

2. It is more effectual. 

M. Bergeon afterwards passes in review the action of the needles in the dif- 
ferent species of cataract, and finds that the utility of his instrument is princi- 
pally obvious in soft, liquid, or milky cataracts, capsular or capsulo-lenticular 
ones, 8cc. He undertakes afterwards to combat the objections which might be 
brought against his procedure, the only one which seems to him to have any 



Surgery. 247 

foundation is this, that in gliding over the iris, in touching the ciliary bodies in 
certain points, an internal inflammation of the ocular globe might be produced; 
but the other methods are not exempt from these reproaches.-— Za Lancette 
Frangaise, Oct. 1st, 1833. 



SURGERY. 

61. New Method of Extracting the Stone from the £ ladder, by a Perinseal In- 
cision. — Dr. Mariano Pantaleo, the author of this method, remarks that the 
lateral operation is the one which has united the suffrages of the greater num- 
ber of physicians, and that the only valid objection which can be made against 
it is, that it does not give a ready passage to large calculi. This inconvenience 
the author proposes to remedy by making a double incision of the prostate 
gland, but not after the method of MM. Dupuytren and Senn. Thus the left 
moiety of the incision regards the ascending braneli of the ischium, as in the com- 
mon lithotomy, while the other half is directed obliquely upwards, and to the 
right side. 

According to Dr. Pantaleo, it is the superior portion of the prostate gland 
which offers the greatest resistance to the dilatation of the neck of the bladder 
wherever the incision is made low down; hence the most rational method is 
that by which this obstacle is overcome, and it was by following this principle 
that Martineavi, according to the author, obtained his brilliant success. 

The bilateral operation, as proposed by M. Dupuytren, has the advantage of 
giving passage to very large calculi, but is attended with some inconveniences; 
thus it exposes us to divide the bulb of the urethra, which is so much deve- 
loped in old subjects, and particularly in calculous patients^ or if we approach 
the incision too close to the anus, in order to avoid it, we run the greater risk 
of dividing the intestine. The incision of Beclard avoids the bulb, but it is too 
near the rectum, and not being parallel to the external incision, gives rise t© 
the danger of an infiltration of urine. 

Finally, the two incisions practised laterally by M. Dupuytren, leave the su- 
perior portion of the prostate gland untouched, and others do not remove the 
obstacle which has been noticed to the dilatation of the neck of the bladder. 

The author's instrument is a double lithotome cache, the blades of which se- 
parate opposite one another, and to the usual extent. He makes an incision in 
the ordinary manner along the left side of the perineeum, opens the membranous 
portion of the urethra, and introduces the hthotome along the sound into the 
bladder. Having estimated the volume of the calculus, the blades of the litho- 
tome are nov/ opened to the proper size, the handle so fixed that the internal 
incision shall be exactly parallel to the external one, and the instrument is 
drawn outwards; hence results an inferior incision on the left side of the pros- 
tate, and a superior one on the right, or, in other words, the gland is divided 
by an oblique diameter, running upwards, and from left to right; this, accord- 
ing to the author, gives the most favourably disposed wound for the extraction 
of a stone; it is very regular, parallel to that of the integuments, and readily 
dilated.— i>ance^, July 12th, 1834. 

62. Treatment of Club-foot, by Dividing the Tendo-achillis,- a new Operation. 
By Dr. Louis Strotvieyeb,. — A division of the tendo-archilles has only been pro- 
posed in cases of amputation of the foot, by the method of Chopart, after which 
operation the foot is apt to be drawn backwards by the muscles on the back of 
the leg, predominating over those left upon the front part. This operation was 
received at first but coolly, and as cases suitable for its application v/ere of very 
rare occurrence, it had fallen into complete neglect, when it was revived by 
Delpech for the relief of those cases of club-foot, termed pied equin where 
the heel is drawn forcibly backwards. It is based upon the important fact. 



"248 QUARTERLY PERISCOPE. 

that in all cases of rupture of the tendoachillis, instead of an immediate re- 
union taking- place between the two extremities of the tendon, a sort of pad 
is found between them, which in time elongates itself to such an extent, that 
the entire length of the tendon is frequently very much increased, whilst at the 
same time its original strength is not impaired. The two following very interest- 
ing cases reported by Dr. Stromeyer prove that the theory of this practice is 
borne out by experience. 

Observation I. — George Ehlers, set. 19, a student of the seminary of Hanover, 
had laboured under a deformity of the left foot, which according to the state- 
ment of his parents, had first appeared when he was four years old, and without 
any manifest cause. He had been subjected at this time to various treatments, 
which had produced temporary benefit, but in spite of every thing- the disease 
continued to increase, and at last became so bad that the patient was unable to 
walk a step. From the application of the different machines, &c. employed to 
keep the foot in a proper position, excoriations, and even ulcerations of some 
depth were produced, which after a time became complicated with caries of the 
metatarsal bone of the little toe, that required several years for its cure. In 
consequence of the pain and distress produced by almost every method of treat- 
ment, the parents determined to let nature have her way, and discarded every 
thing like regular treatment, merely attaching a wooden leg upon which the 
tuberosity of the ischium rested? with this contrivance the patient made shift 
to get along. In the month of October, 1830, the patient was brought to the 
orthopedic establishment of Dr. Stromeyer for the first time, and presented 
the following appearances. The left foot excessively deformed, the toes being 
forcibly drawn downwards and inwards; the external margin of the foot cor- 
responded precisely with the axis of the leg, and the whole foot was extended 
to such a degree by the contraction of the muscles of the calf of the leg-, that 
the margins of the foot formed a straight line with the anterior face of the leg-. 
On the upper portion of the external margin of the foot there existed two callous 
spots, the remaining of those which had been formed in this position when the 
patient could walk. The degree of mobility enjoyed by the foot was extremely 
small, and the whole leg was very much emaciated. By the continued use of 
the wooden leg the limb had acquired a remarkable deviation from its natural 
condition; the deviation consisted in a projection outwards of the leg from the 
knee-joint. The length of the two extremities were nevertheless nearly equal, 
allowing for the great deformity existing in one of them. The right was large, 
and the muscles well developed, the superior surface of the right foot, how- 
ever, was so projecting that the foot seemed to be much shorter than na- 
tural, and approached somewhat the same species of deformity with which 
the other was affected. Yet this peculiar conformation did not interfere with 
the motions of the foot. This circumstance should be recollected, as it shows 
that the original cause of club-foot may have its origin in the spinal marrow. 
The prognosis in a case of such great deformity was of course extremely un- 
favourable, yet as the patient was resolved to submit to any plan of treatment 
whatsoever that might be advised. Dr. Stromeyer determined to make an effort 
to relieve him, and he was the more willing to do this as there still remained 
some degree of mobility in the joints of the foot. Powerful extension was re- 
sorted to, and continued for the space of three months without any amelio- 
ration in the position of the foot, except that its sole was brought a little 
nearer the horizontal line. Excoriations were also produced by the ban- 
dages. After being fully convinced of the inutility of this plan, the Doctor de- 
termined to perform as a ** dernier resource," the section of the tendo-achillis. 
To this the patient readily consented. On the 28th of February, 1831, the 
operation was performed in the following manner. The patient was placed upon 
a table, with his left side presenting to the operator. The knee was firmly 
fixed by an assistant, and the foot firmly supported, and fixed in such a manner 
as to cause the tendo-achillis to be put upon the stretch by another. The in- 
strument, a very narrow, sharp-pointed bistoury, was then introduced between 



Surgery. 249 

the tendon and the tibia, about two inches above the Insertion of the latter, 
and in such a manner that its back part looked towards the bone, and its cut- 
ting edg-e towards the tendon, the latter was then divided. The object in using" 
a small knife was to make the external wounds as small as possible, in order to 
prevent the introduction of air into the cavity, and the consequent suppuration 
and exfoliation of the tendon. This was divided without an opening, except 
that made by the knife in entering, being made in the skin. The haemorrhage 
was little or none. The interval between the two extremities was about three- 
quarters of an inch in length, but the position of the foot was not materially al- 
tered. By extending the foot, the two cut extremities were placed in imme- 
diate contact. The external wounds made by the bistoury were covered over 
with a piece of adhesive plaster, and two long pads placed one on each side of 
the tendon, and confined by a few turns of the roller, which was afterwards 
carried over the foot, and so arranged as to keep it in a state of extension. It 
was not judged necessary to use a splint, the muscles of the leg being in such 
a state of atrophy that there was no apprehension of a displacement of the ex- 
tremities of the tendon by their contraction taking place. The limb was placed 
upon its outer side, and supported in an elevated position by pillows. By the 
tenth day the two extremities were found to be perfectly united to each other^ 
and the pain and slight degree of swelling that had existed for the first few days 
after the operation, had entirely disappeared. It was now deemed proper to 
commence with the extension of the intermediate substance. The foot at this 
time formed with the leg a very obtuse angle. The degree of extension for 
the first few days was very moderate, and applied with great caution for fear of 
breaking up the new adhesions, and moreover to avoid giving the patient un- 
necessary pain, who complained of pain in the cicatrix whenever it was carried 
to any extent. In eight weeks from the time when the extending bands were 
first applied, the foot was found to form with the leg a complete right angle. 
The Dr. was now enabled to apply a sort of boot, furnished on the outer side 
with an iron splint, which was interrupted opposite the ankle joint by a hinge. 
The hinge was furnished with a screw, by which the angle of the foot with the 
leg might be changed at pleasure; with the aid of this boot, and with a stick 
the patient was enabled to walk about his room, but the limb weakened by long 
inaction, soon became fatigued and swollen. From this time forward he con- 
tinued gradually to improve, though the swelling for which frictions with cam- 
phorated spirit was prescribed occasionally would show itself. In two months 
time this had entirely disappeared; the foot formed with the leg a perfect right 
angle, its external margin being perfectly horizontal; the muscles of the calf of 
the leg had acquired considerable size, though still situated higher up than 
natural; his gait was without any imperfection whatever; in short a complete 
cure had been effected. The patient was examined eighteen months after the 
performance of the operation, and it was found that no disposition to a return 
to its unnatural position had been manifested by the foot, the knee had also re° 
gained its natural direction, and the patient walked without a stick. It is ob- 
vious that the success met with in this case was dependent upon the division of 
the tendon; the muscles of the calf having remained almost in the same position 
during the whole treatment, shows that it was not by an extension of their 
fibres that the cure was effected. 

Observation II. — The second case is that of a M. Blumenthal, set. 32, whose 
left foot was the seat of the deformity. He stated that at the age of eighteen 
months he was attacked with an inflammatory affection, accompanied with. 
convulsions, and that during this illness the deformity had commenced. The 
deviation increased gradually from this time forwards, but had not until within 
a few years past prevented his walking about and attending to his business; 
latterly, however, it had arrived to such a degree, that he was sometimes 
obliged 10 confine himself to his bed. Upon examination, the foot seemed to 
have almost reached the highest grade of deformity. Its outer margin, as well 
as the toes, were drawn downwards and inwards to such a degree, that in walk- 



£50 QUARTERLY PERISCOPE. 

ing" the back of the foot came in contact with the ground, and from the con- 
tinual pressure which it had necessarily undergone, was covered by a thick and 
horny collosity. The point of the foot deviated so much from its natural posi- 
tion, that in walking it looked directly backwards, and by coming in contact 
with the ankle joint of the other foot, kept it in a constant state of irritation. 
The heel was elevated to some height, and did not touch the ground at all in 
walking. The muscles of the calf were sufficiently well developed, though si- 
tuated higher up the leg than natural,- the tendo-achillis on the contrary was 
smaller than natural. Notwithstanding the extreme degree of deformity, the 
articulations of the foot were moveable, though it is true not to any great ex- 
tent. The first thing that was done in this case was the removal of the callous 
from the back of the foot, and from its outer margin; (the callous in some places 
was half an inch thick.) The foot was then dressed and placed in the extend- 
ing machine for three weeks, with the design of placing the foot under the axis 
of the leg, which was in part effected. On the 12th of June, 1832, the tendon 
was divided as in the first case, with the exception that the knife was introduced 
three i«ches instead of two, above the insertion of the tendon, in order that the 
newly-formed tissue might be as far removed as possible from the spot upon, 
which the extending bands were afterwards to be placed. The dressings here 
also resembled those made use of in the first case, only it was thought better 
from the size of the muscles of the calf to place a splint upon the anterior face 
of the foot, so as to prevent their spontaneous contraction. In a short time after 
the operation the patient was attacked by cramps in the calf of the leg that had 
been operated upon, which came on the moment he went to sleep; in this way 
he was kept awake all night. The next day the bandage was taken off, and 
the extremities of the tendon brought into contact, and a roller passed up the 
leg to prevent the contraction of the muscles. Nevertheless they reappeared 
more violently than before, and the patient passed another sleepless night. The 
bandage was taken off, and the splint applied, the foot and lower part of the 
leg only being enveloped by a roller. From this time the cramps never again 
appeared. Ten days having elapsed, and the extremities of the tendon being 
iirmly united, the apparatus for extension was applied. In about ten weeks 
after the performance of the operation, the patient quitted Hanover in the fol- 
lowing condition. The foot formed with the leg a complete right angle, and 
in walking its sole came into uniform contact with the ground. There never- 
theless remained some traces of the original deformity. The back of the foot 
was still very convex, v^'hich proceeded from a manifest curvature in the meta- 
tarsal bones; and the thenar eminence was also turned inwards. When walk- 
ing with care the foot was turned outwards, when, however, he walked with- 
out paying any attention, or very quickly, the point of the foot still directed 
itself a httle inwards, though without striking against the other foot. The mus- 
cles of the calf of the leg were well developed, though situated higher up than 
in the right. It was also impossible in this case, as in the other, to determine 
with certainty the length of the substance formed between the divided extre- 
mities of the tendo-achillis, although the space made by a division of the 
tendon was more perceptible than in the first. 

There is probably no other case on record, where a deformitj'- of the foot, so 
extreme in its character, and of such ancient date, has been converted by the 
efforts of art into a condition so nearly normal. The circumstances which in- 
duced the doctor to undertake the treatment of the case should also be recol- 
lected; they were — 1st. The ankle joints being still slightly moveable; 2d. The 
muscles of the calf of the leg being still tolerably well-developed; and finally, 
the foot being covered by a solid dermoid coat, there was not much tendency 
to excoriation. It yet remains for us to describe the apparatus by means of 
which this extraordinary cure was effected. It consists of a splint, somewhat 
wider than the leg, upon which the latter was made to rest. At the point cor- 
responding with the heel, the splint was divided by a mortice cut in its centre 
into tv/o equal parts, which were made to extend some inches beyond the sole 



Surgery, 251 

of the fool. To the bottom of the mortice, and close to the heel, a sort of 
wooden sole was attached by a moveable articulation, by which means the 
ang-Ie which it formed with the long- splint mig-ht be either increased or dimi- 
nished. Two cords were attached to the superior third of the wooden sole, 
and then carried over two pullies, solidly fixed to the edges of the long splint, 
upon a line corresponding to the inferior third of the leg. After they had passed 
round the pullies, they were brought down the edges of the sphnt until they 
reached the extremities of the arms of the mortice, where they were attached 
to a small cylinder, which turned with a crank. By fixing the foot firmly to the 
wooden sole, and thus turning the cylinders to which were attached the cords, 
the whole foot might be made to approach a right angle, and be retained in 
that position as long a time as could be supported by the patient. The degree 
offeree that could be applied with this apparatus, although very considerable, 
could nevertheless be limited by reversing the action of the cylinder to any ex- 
tent whatever.— Gaz. Med. Sept. 28thy 1833, from Bust's Mag. Vol. XXIX. 

63. Subcutaneous Vascular Nxvus. — W. C. Worthixgtox, Esq. reports in 
the Lancet^ (12th July last,) the case of an infant with this disease, situate on 
the right side of the chest just below the axilla, in size a little exceeding 
a shilling. The surface of the n^vus was rubbed a few times with an oint- 
ment of tartar emetic, when it became covered with pustules, which were soon 
confluent; granulations sprung up, which were occasionally touched with the 
nitrate of silver; simple adhesive plaster was then applied as a dressing, and a 
complete cure effected, nothing remaining but a superficial cicatrix. 

Mr. C. Hickman, in a former number of the same journal, (for April, 1834,) 
reported a case of vascular nsevus cured by the application of a liniment com- 
posed of tartar emetic and olive oil. 

64. Imperforate Anus existing for Tivo Months. — The subject of this case was 
a female infant who, when two months of age, was in an almost dying condi- 
tion, taken to M. Caussade. This infant vomited fscal matters; had hiccup; the 
pulse was small, contracted; the face livid, and covered with sweat; the voice 
almost extinct; and the abdomen much distended. She had been placed out 
to nurse immediately after her birth; her clouts y^^ere. observed to be wet and 
slightly soiled, but the nurse never observed any alvine evacuation as in other 
children. As the little one was, however, in good health, and even grew fat, 
the nurse continued to suckle her without seeking the cause of the absence of 
alvine evacuations. On examining the infant, M. C. found that there was no 
anus, or trace of one. She passed through a capillary opening at the posterior 
part of the vulva, very near to the hymen, a thick and yellowish fluid, which, 
when the infant cried and struggled, spouted out as if discharged from the spout 
of a small syringe, f During the straining of the infant, a tumour projected in 
the perinasum, and in a part of the breech. To relieve the perforation, M. 
Caussade made an incision three or four lines in depth in the place which the 
anus ought to have occupied. He found at the bottom of the incision a mass 
of hard and yellow fzecal matters. It was necessary to break them up, and they 
were removed by means of a scoop. Several injections were administered, 
which brought away a large quantity of yellow liquid matter. The wound was 
kept open by a lint ttnt. The next day the faecal matters were readily dis- 
charged, all the unpleasant symptoms ceased, and the health of the little patient 
was restored. — Gazette des Hupitaux, March 29th, 1834. 

65. Successful Treatment of Disunited Fracture by the Tourniquet. — In a case 
of disunited fracture of the femur of twenty-one weeks' standing, and which 
resisted all the ordinary means of procuring union, has been successfully treat- 
ed in St. Bartholomew's Hospital by the application of tourniquets lightly 
round the fractured part of the limb. The patient was middle-aged, and in the 
enjoyment of excellent health.— Xond Med, and Surg. Journ. Sept. 28ih, 1833. 



252 QUARTERLY PERISCOPE. 

G6. Luxations of the Humerus. — M. Geharb recommends the followiiicj 
method for the reduction of hixations of the humerus. He states, that he has 
employed it successfully in every case, (eight cases,) in which he has resorted 
to it, of luxation of the humerus downwards, and more or less forwards or back- 
wards. The patient being- seated on a chair, an assistant placed on the unin- 
jured side, passes his arm around the neck of the patient, and with his two 
hands crossed upon the dislocated shoulder, produces counter-extension. The 
operator placed on the injured side, raises the limb from the body, flexes the 
forearm on the arm, holds it, or has it held against the chest of the patient, and 
placing his left forearm under the upper portion of the luxated bone, as near 
as possible to the axilla, he flexes this forearm by pressing it against the patient, 
so that the cubital extremity of the luxated humerus is supported upon the 
side of the operator, who then exerts upon the luxated part a single traction, 
which suffices to effect reduction by replacing the head of the humerus in the 
glenoid cavity. It is essential to retain the inferior extremity of the luxated 
bone, firmly supported against the side, and as near as possible to that of the 
patient. In ordinary circumstances, a common man need not exert more than 
one-third of his strength to eflTect reduction, which is accomplished by a single 
effort, and without the patient having time to complsdn.— Journal Hebdoma- 
daire, 11. 126, 1834. 

67. New Pud for Trusses. — MM. CRESsojf and SAsrsois- have devised a new 
pad for trusses, which is said to be very superior to the con.mon one. This 
new pad is formed of gum-elastic, and is made either solid or hollow, in the lat- 
ter case it is properly distended with air, which may be either perm.anently 
confined, or the pad is so constructed that the quantity of air in it may be in- 
creased or diminished at will. — Gaz. Med. March 15th, 1834. 



MIDWIFERY. 

68. Rupture of the Vagina during Delivery. — A healthy woman, about thirty 
years of age, and who had borne one living child, was the subject of this case. 
The labour had continued about eleven hours, and had been rather difficult 
and tedious in consequence of an edematous swelling of the labia, and of the 
lower extremities. The head had already descended fairly into the cavity of 
the pelvis, and the pains had become more severe, when on a sudden they 
ceased entirely; the patient complained of a sharp pain in the right iliac region; 
vomiting and general coldness succeeded, and the patient died in the course 
of an hour. 

The diflTerent parts of the foetus could be distinctly felt through the abdomi- 
nal parietes. No outward haemorrhage occurred. 

Dissection. — A small quantity of blood was found in the abdomen; the uterus 
empty, and contracted upon itself, was inclined somewhat to the right side, 
and ])resented in all respects a normal appearance. The fatus had escaped 
into the cavity of the abdomen, and its body was enveloped among the intes- 
tines, the knees being placed against the abdominal parietes, while the head 
remained still in the passage, and was, as it were, incarcerated there by the 
edges of the opening, firmly applied round the neck. The laceration had 
taken place in the upper part, or vault of the vagina, which was enormously 
stretched, the child being unusually large. The placenta had descended hito 
the vagina, and was partially protruded through the rent into the abdomen. — 
Med. Chirurg. Rev. from ISiehuld's Journ. der Geburtshulfe. 

69. Injections of Cold Water into the Umbilical Cord to Promote the Separation 
of the Placenta. — Professor Hohl states that this method, first recommended by 
M. Mojon, will often succeed perfectly if it be used sufficiently early, asd 



Chemistry. 253 

provided the vein does not contain too much blood; for sometimes cases occur 
in which it is not possible to dislodg-e the blood which the vein contains. One 
injection will frequently suffice. If we listen with the stethoscope over the re- 
gion of the womb, where the placenta is attached, while a quantity of water is 
injected into the cord, a noise or rlionchus coming- as if from a distance is heard; 
this noise is quite distinct from that of any pulsation. In favourable cases the 
sound becomes louder and stronger, and in addition to it, other rhonchi of a 
more sibilant or whistling- character becomes audible. Professor H. states, 
that he never could hear any of these last described sounds in cases in which 
the placenta remained obstinately attached; they would therefore seem to be 
connected with the contractions of the uterus. These contractions are neces- 
sarily very imperfect, when the placenta remains fixed; and hence perhaps the 
absence of the sounds in these cases. Professor H. recommends that the in- 
jection of the cord be used even when it does not succeed of itself, and when 
therefore it is necessary to remove the placenta by manual assistance, it may 
be a serviceable adjunct. 

The most frequent cause of failure with the injections alone, is spasmodic 

Rtv. from Jlllgememe Medic. Zeitung, 



CHEMISTRY. 

70. On a New Mkalo'd substance called Quinodine discovered in Yellow Bark. 
By MM. Henry and A. Delonbuk. — This substance is white, crys'calli/able in 
prismatic needles, in the state of a hydrate. It melts into a mass of a resinous 
appearance, only at a much higher temperature than that required for the fu- 
sion of quinine. It is extremely bitter, especially when dissolved in alcohol or 
an acid. Alcohol of the sp. gr. of .949, or even .963, holds it in solution, but 
by the spontaneous evaporation of this liquid it is deposited either in crystals, 
or at first in a sort of resin, which, when moistened by alcoholic water, changes 
by degrees, on exposure to the air, into beautiful crystalline needles. Cold sul- 
phuric ether dissolves also a small quantity of it. These needles, collected and 
dried, effloresce in dry air. They speedily turn the syrup of violets green, and 
restore to its blue colour turnsole paper reddened by an acid. 

They combine perfectly with sulphuric, hydrochloric, nitric and acetic acids 
to form white pearly salts, very crystallizable like those of quinine and precipi- 
table by soda, &.c. The hydrochlorate appears only more needle-like faiguill^J 
while with quinine it is often in plates like common boric acid. Quinodine at 
a high temperature is decomposed, diffusing- at first an aromatic, then an empy- 
reumatic animalized odour, and a part of the alkaloid is sublimed in the midst 
of its volatile products. 

Its elementary analysis has not yet been determined, but it appears to be rich 
in azote. It resembles quinine in its form, small degree of volatility, its solu- 
bility in alcohol much diluted, and its saline combinations. It differs from this 
substance by its great tendency to crystallize, and its being less fusible, its 
being less soluble in sulphuric ether, and by the property which it has in its 
resinous state of assuming in the air, the form of crystals when moistened with 
alcoholic water, — an effect which its discoverers have not observed to occur with 
pure quinine. 

Quinodine is found in the yellowish waters which float on quinine and cincho- 
nine after the distillation of the alcoholic tinctures and the preparation of qui- 
nine. It is accompanied by a yellow substance supposed to be an acid. 

The discovL-rers promise hereafter to g-ive the processes for procuring quino' 
dine pure. — Edinburgh Med. and Surg. Journal, from Journal de Pharmacie, No- 
vember , 1833. 

No. XXIX.— November, 1834. 22 



254 QUARTERLY PERISCOPE. 

71. Netv Ether. — M. Pelouze lately discovered a new ether, which he calls 
*• Hydrocyanic," while examining- the effects produced by heat on a mixture 
of tlie sulpho-vinate of barytes with cyanuret of potassium. This ether is liquid, 
colourless, possesses a very pungent alliaceous odour, and acts energetically on 
the animal economy. It is inflammable; boils at 82° under atmospheric pres- 
sure; its density is 0.787 at a temperature of 15°; it is but little soluble in water, 
but is perfectly so in alcohol or sulphuric ether. It does not precipitate the 
nitrate of silver, and in this respect resembles hydrochloric ether, which does 
not decompose the salt until it has been destroyed by the action of heat. 
M. Pelouze regards the hydrocyanic ether as composed of equal volumes of 
olefiant gas, and of the vapour of prussic acid condensed one-half. The idea of 
searching for this ether, was suggested to M. Pelouze by an observation of M. 
Leig-e, who discovered a peculiar substance possessing acid properties, and 
formed by the action of barium on the sulpho-vinate of barytes; its composition 
was such as to lead to the conclusion, that it was a kind of alcohol, in which 
the oxyg-en was replaced by sulphur. — Gazette des Hupitaux. 



MISCELLANEOUS. 

72. Beaumont's Experiments. — Our countryman, Dr. Beaumo:^t's work, en^ 
titled " Experiments and Observations on the Gastric Juice, and on the Phy- 
siology of Digestion," was presented to the French Academy of Sciences at 
their meeting of the 10th of March last; and on motion of M. Arago, a commit- 
tee was appointed to examine these experiments in order to suggest new ones 
if those already made were not sufficient. M. Roux stated, that a case similar 
to that of Dr. Beaumont's had occurred at Paris. The subject of it was a wo- 
man, and experiments relative to digestion had been made upon her, which 
were supposed to have hastened her death. — Gaz. M6d. March 15th, 1834. 

73. Examination of the Trials made with Homoeopathic Medicine in the Military 
Hospital of St. Petersburgh. By Dr. Seidlitz. — The celebrated Berlin surgeonj^ 
Dieffenbach, has very truly said, that this new doctrine " offers a vast fiela to the 
most absurd reveries and antiquated superstitions, which some shallow men always 
prefer to whatever is clear and palpable;" and all who have perused their oracu- 
lar book or institute, the *' Organon of Medical Science" as it is modestly called 
by the author, must have arrived at the same conclusion. There is an utter 
destitution of all rational proofs of the opinions, or rather dogmas, there an- 
nounced. Proceeding from a few appearances, at best of very exceptionable 
accuracy, Hahnemann leaps at once to the assertion — that no medicine ever 
cures a disease, unless it is capable of exciting in a healthy system symptoms 
altogether analogous to those which it is employed to relieve. Almost all chro- 
nic diseases, we are informed, are caused by ill-cured itch. There is no proof 
given of this — only we are told that it is so! Then another wondrous disco- 
■very is, that the ten-millionth part of a g-rain of charcoal is a very active agent 
in some diseases; and that many medicines are extraordinarily exalted in effi- 
cacy by the number of times the vial which contains them in solution is shaken! 
Yet, such is the hungry credulity of mankind, that all these g-ood things are 
swallowed, nay, even digested, if we may judge from the products, we mean 
of the brain, which, with all suitable consistency, are inversely proportionate 
to the ingesta. Born and nursed in Germany, that fatherland of wild phantasies, 
this curious doctrine has been diffused over Switzerland and Italy — has entered 
France, and reached Lyons, and even Paris. Like every novelty, it blinds and 
infatuates many for a time. When we hear of old-established practitioners, not 
to allude to numerous young men, who cannot possibly be influenced in their 
choice by any selfish or mercenary motives, forsaking- their accustomed ways, 
and fondly embracing the most ridiculous vagaries as the only ti-uth, can we 



Miscellaneous. 255 

explain such an occurrence in any other way than by thinking of many other 
absurdities which have been for a time tolerated, admired, adopted, applauded, 
and then ridiculed, scoffed at and despised. 

Well has it been said by one of the great German poets, Goethe. — "For 
even when all ideas are awanting", a word or two will supply their place; with 
words you may fig-ht most famously; with words you may build a system of phi- 
losophy; if a man but hears words he will believe them." To give a specimen 
of the practical excellencies of homcEopathism, we cannot do better than allude 
to the course which has been pursued by the Russian government towards it. 
A Saxon physician. Dr. Hermann, the great apostle of the system in Russia, 
was invested by the Grand Duke Michael with full powers to display, in a 
course of chnical experiments, its superiority over the common practice and 
theory of the day. 

One of the wards of the Hopital de Tuttschin, which contained a number of 
soldiers affected with fever and dysentery, was allotted to his special manage- 
ment during- a space of two months. 

The following table exhibits the results: — 

Patients. Cured. Died. Rem. 

Common method - 457 - 364 - — - 93 
Homoeopathic do. - 128 - 65 - 5-58 

Notwithstanding" the results of this experiment were so decisive against the 
new doctrine, the ministers of the Russian government some time afterwards 
summoned Dr. H. to Petersburg", gave him authority to select his own hos- 
pital, and to make any arrangements hei thought fit. The wards were fresh 
painted, and every hygienic precaution faithfully executed. Even the kitchen 
was placed entirely under his controul and superintendence; and in order 
to prevent the possibility of any interference a sentinel was placed before 
the door, and none permitted to enter during- the occasional absence of Dr. 
Hermann. His first request respecting- the patients was a very moderate and 
modest one, viz. that none should be sent to his hospital who laboured under 
ulcers, syphilis, dropsy, phthisis, &c. and that he should have the selection of 
all his cases!! Even under these most fortunate circumstances, the results 
were most unfavourable to the new practice; the proportion of deaths to re- 
coveries was much higher than in ordinary practice, and the duration of the 
treatment was always protracted and tedious. Here is a specimen of the re- 
ports. The case is pronounced one of peripneumonia. 

History. — Patient ill for seven days; severe frontal cephalalgia; pains in the 
eyes; tongue clean but dry; thirst; bitter taste in the mouth; anorexia; bowels 
open; dry coug-h during- the night, and this is accompanied with pains in one 
side, which are increased on pressure; pains felt in the arms; skin cool; pulse 
full and not frequent. 

An infinitesimal dose of arnica ordered. Next day but little change; but after 
this the symptoms gradually subsided, and the patient was discharged cured on 
the nineteenth day after admission. 

A well-marked example of peripneumonia indeed!! A slight catarrh with 
an equally slight disturbance of the stomach. Forty-seven cases are detailed by 
Dr. Seidlitz, many of which are still less entitled to the epithets bestowed upon 
them.~^ey. Med. Feb, 1834, from Hecker's Annals^ November^ 1833. 

74. Death of St. John Long. — This notorious individual, the most successful 
quack of the day, in one sense of the word at least, died lately in London. It 
appears that he fell a victim to the very disease, (pulmonary consumption,) for 
the cure of which he pretended to possess an infalhble cure. A remarkable 
commentary this upon the blind credulity of his numerous dupes, among whom 
were several persons of rank, and in other respects of intelligence. 



( 256 ) 



AMERICAN INTELLIGENCE. 



Account of the Cholera in New York during the present year. By C. A. Lee, M. 
D. — [Communicated in a letter to the Editor.] — Dear Sm, I embrace a leisure 
moment to g-ive you a short account of the cholera, since its reappearance in 
our city. About the 1st of July bowel complaints began to prevail very exten- 
sively, especially among the poor residing in crowded and ill-ventilated apart- 
ments, and occasionally a case occurred with the same symptoms as attended the 
cholera in 1832. Indeed, sporadic cases of this disease have from time to time 
appeared here since its prevalence in that fatal year, several of which occurred 
during the last winter and spring. On the 14th of July, a few days after its ap- 
pearance in Canada, I attended a patient, who had been employed in rafting 
and been much exposed to wet and fatigue; an intemperate man, and living in 
a filthy habitation. I found him with violent cramps, cold, slirivelled skin, rice- 
water dejections, and almost imperceptible pulse, and the other symptoms cha- 
racterizing this stage of cholera. He recovered. 

On the 9th of August the board of health began to report, and reported 
fourteen deaths as having taken place since the 23d of July. From that period 
they continued their daily reports until the 16th instant, including fifty-three 
days, the total number of deaths being 636; 168 being hospital patients, 331 
city, and 69 at Bellevue. The whole number reported by the city inspector, 
however, during the same period, is 734; and if to this we add the number for 
the last week, 93, we have 827 deaths to September 20th, averaging about 13 
deaths per day. This, for a population like ours, is certainly very light; much 
more so, indeed, than in most of the places north and west where it pre- 
vailed the past season. Compared with 1832, it has not prevailed to one- 
quarter the extent it did then; nevertheless, it is worthy of remark that for the 
last seven weeks the mortality by all diseases has been more than half as great 
as in any seven weeks of 1832. In that year, during the greatest prevalence 
of cholera, the number of deaths by all diseases was 4,158; during the past 
seven weeks 2,376. The whole number of deaths in 1832 was 10,359; in 
1833, 5,746. This apparent anomaly may perhaps be explained when we con- 
sider the large number of deaths from other analogous diseases of the gastro- 
intestinal membrane, such as dysentery, cholera infantum, diarrhoea, enteritis, 
and common cholera morbus. Of these, cholera infantum furnishes much the 
largest proportion. 

Another fact worthy of note perhaps, is the exemption in a very great de- 
gree of those sections of the city which suffered severely in 1832. This has 
not been uniformly the case, but sufficiently so to excite public remark. For 
example, in the 1st, 3d, 5th, and 15th wards there have been more cases of 
cholera than in 1832. In Warren street, 3d ward, there have been from fifteen 
to twenty deaths; in 1832, only three or four. In Anthony street, 5th ward, 
on the west side of Broadway, it is said there have been at least one hundred 
cases; in 1832, not more than twenty in the same district. The parts of the 
15th ward which were mostly the seats of disease in 1832, have this year 
been nearly exempt. In 1832 the number of cases in the 6th ward was seven 
hundred, this year about seventy-five. The 12th ward, which suffered se- 
verely in 1832, has nearly escaped the present season, and so of other dis- 
tricts of the city. Some of the most low, filthy, and confined parts of the city 
have entirely escaped, while other portions of an opposite character have suf- 
fered. There have been several remarkable instances in v/hich whole or nearly 
whole families have been carried off, and that without the aid of any known 



American Intelligence, 257 

local causes. In such cases I have generally been able to trace It to the effects 
of fear, grief, anxiety, watching, or fatigue. Even the common people, with 
few exceptions, consider the disease non-contagious; accordingly, there has not 
been that panic which prevailed during the former period, and which drove a 
large portion of our citizens to the country; nor a want of nurses and attend- 
ants upon the sick, (not to say doctors,) which rendered the establishment of 
hospitals absolutely necessary. The doctrine of contagion, I am confident, has 
gained few converts since the reappearance of cholera in New York the present 
season. 

On a former occasion, I communicated to you briefly my views as to the pa- 
thology of the disease, and additional experience and observation serve to con- 
firm me in the belief of their correctness. Indeed, after the numerous facts 
presented by Broussais, Cruveilhier, Andral, Hope, Jackson, and other able 
pathologists, there seems to be scarcely any thing wanting to place the patho- 
logy of this disease on an immoveable footing. The results of fifteen autopsical 
examinations of cholera subjects fully confirms me in the behef of the doc- 
trine that the disease consists primarily in an exalted action of the capillary and 
secretory vessels of the gastrointestinal membrane, resulting from a high ab- 
normal state of irritation. The views presented on this subject by Dr. Jack- 
son in this Journal, are luminous, incontrovertible, and above all praise. They 
have received, and will continue to receive, the assent of most candid physi- 
cians who diligently employ the same means of eliciting truth that he has done. 

I have noticed, in a late work on Cholera, by Dr. Casanova, an attempt to 
controvert this doctrine on the assumed ground that "the sinking of the circu- 
lation in cholera patients, and the weak action of the heart, precedes the cho- 
lera evacuations." Now, in the first place, admitting this to be a fact, which I 
do not, it does not by any means follow that the subsequent phenomena are not 
the result of a vital reaction developed on the gastro-enterltic surface, causing 
choleric discharges of an active or inflammatory character. If the experiments 
of Majendie, Orfila, and other physiologists are to be depended upon, such, in- 
deed, is the effect of all poisons taken into the circulation, and in consonance 
with this general law of the elimination of morbid substances from the circula- 
tion, such also should we expect to occur in throwing off the virus of cholera. 
But I apprehend that few physicians have an opportunity of examining cholera 
patients previous to any evacuations, as a case cannot be known to be cholera 
till some of its characteristic symptoms appear. Of a large majority of those, 
however, whose history is ascertained, it is found that simple diarrhoea, with or 
without pain, constitutes almost the only symptom, while the strength remains 
for some time unimpaired and the circulation active. 

Those cases form an exception to this remark, where the earliest symptom 
is vomiting, brought on by improper aliment, or the excessive use of alcoholic 
stimulants. These, however, are comparatively rare. On this point medical 
testimony is almost unanimous. Dr. Kirk, of Greenock, in his able pamphlet, 
remarks, *' there is still a question among practical men, if a state of excitement 
always precedes the attack? I think it does. In all cases I have had it in my 
power to observe from the first it has done so." Other authorities to the same 
point might be quoted, but I forbear. I recollect, indeed, one singular instance, 
where a medical man from the country, after having gone through the wards of 
the Greenwich Cholera Hospital, in which were about sixty patients in all stages 
of the disease, fell insensible to the floor, and was shortly afterwards attacked 
■with the disease. But in this case the individual was labouring under excessive 
fear, and his tongue was completely coated with a white fur, indicating a high 
state of irritation of the stomach and bowels. 

The theory of Dr. C. that the disease consists principally in spasm, particu- 
larly of the heart, is entirely unsupported by facts or reasoning. It is indeed 
less satisfactory than most of the pathological doctrines against which he con- 
tends, and the treatment which he proposes, viz. injection of tobacco smokcp, 
is no less ineffectual than his conclusions are unsound. 

22* 



258 QUARTERLY PERISCOPE. 

With respect to the treatment of cholera, though there has been by no means 
so great a degree of uniformity as could be desired, yet a majority of the prac- 
titioners of this city have pursued a course if not dictated by the pathology al- 
ready hinted at, yet certainly in consonance with it. Accordingly, stimulant 
cathartics have been very generally proscribed, while ice has been extensively 
used internally, and revulsives to the surface. A few, bold, dashing physicians, 
have persisted in the employment of drastic purgatives, and some valuable lives, 
no doubt, have been sacrificed to this incendiary treatment. It is a singular, 
but lamentable fact, that some physicians will persist in a fatal mode of treating a 
disease; their minds are so blinded by prejudice, or biassed by preconceived 
theory. Let such read the following remark of the illustrious Sydenham, con- 
tained in his treatise of the cholera morbus of the year 1669. " 1 have found 
by much consideration, and by manifested experience, that if I should endeavour 
to expel these sharp humours that are the fuel of the disease, I should do just 
as he that endeavours to quench fire with oil, seeing the operation of the most 
gentle purge would but cause greater disturbance and raise new tumults," &c. 

Notwithstanding the doctrine of the humoral pathology, which influenced his 
practice, should have led Sydenham to have expelled these humours by ca- 
thartic medicines, yet observation and " manifest experience'* taught him that 
this treatment was hazardous, and therefore he abandoned it. The physiological 
practice then is not only the offspring of a correct pathology, but of varied ob- 
servation and experience in difi^erent countries and ages. Let it therefore un- 
dergo the ordeal of fair experiment before it be condemned. 

In the commencement of the epidemic of 1832, I treated many cases of cho- 
lerine, or premonitory diarrhoea, by moderate doses of rhubarb and magnesia, 
or castor oil; but I found that though this course would sometimes succeed, yet 
they frequently terminated in severe attacks of cholera, several of which proved 
fatal. The same occurred in the practice of others, so that those who have seen 
and treated the disease to any extent, have abandoned cathartic remedies al- 
most entirely from the treatment. On the reappearance of cholera the present 
season, I pursued a different course, and with far more satisfactory results. Afte? 
the employment of a Cayenne pepper pediluvium, I directed the patient to take 
a table-spoonful of the following mixture, every five, three or four hours, ac- 
cording to circumstances: — R- Cretse ppt. ^U^s.; Pulv. g. acacise, Sacch. alb. 
aa, 5j.; Sal. sulph. morph. 3j.; Carb. potass, gr. xv.; Aquae menth. sat. ^iv. M. 

This, with farinaceous diet, mucilaginous drinks, and in severe cases confine- 
ment to bed, with general or local bleeding, has succeeded in every instance in 
arresting the disease. Occasionally I have added a small quantity of the tinc- 
ture of kino, galls, or catechu, and sometimes I have thought with advantage. 
A powerful adjuvant in such cases, is a mustard cataplasm to the epigastrium. 
Where the diarrhoea is urgent, or attended with nausea or vomiting, this is in- 
dispensable. If the patient can be got into a warm perspiration, evidencing 
full reaction, he is generally safe. By this plan I succeeded in 1832, in treat- 
ing nearly one hundred children at the Orphan's Asylum with invariable success, 
though two who were taken the day before I commenced attendance, and were 
treated differently, died. To check the vomiting, mustard and other external 
revulsives, with ice, iced Seltzer or soda water internally are by far the most ef- 
fectual remedies. I have found few, if any cases this season, but what yielded 
to this plan. 

In the collapsed state, a large proportion have died under every mode of 
treatment. Most of those cases reported as cures from collapse, were doubtless 
labouring under partial collapse only, a debility of the circulation, with more or 
less coldness of the surface. Such have occasionally recovered under directly 
opposite modes of treatment. 

Violent frictions, with mercurial and stimulant preparations, I have entirely 
abandoned, believing that the alarm and agitation they occasion to the patient, 
more than counterbalances any advantages attending their use. It is but very ' 
rarely that the patient survives a sufficient length of time to produce mercurial 



American Intellio^ence. 259 



"o 



action in the system; and where he does he is very apt to be cut off by cere- 
bral congestion, or the mercurial fever which follows. Besides, if the patient 
recovers, the injurious consequences resulting from saturating the system with 
such a quantity of mercury, are of a most serious nature, and absolutely render 
life a burden. I therefore do not wonder that M. Velpeau, after having exten- 
sively employed mercurial frictions in his hospital in Paris abandoned their use, 
for other less objectionable means; and I fully agree with the editor of the 
Archives Ginerales^ in his No. lor April, 1832, when he says that *' mercurial 
frictions have been followed by favourable results in cases apparently desper- 
ate; but these are too few, and too vague, to justify much confidence.^* Thus 
much would I remark in relation to this remedy; having undesignedly contri- 
buted in bringing it into notice in 1832. 

In collapse, then, I have employed with the greatest success powerful revul- 
sives, such as mustard, Cayenne pepper, flies dissolved in strong acetic acid, 
boihng water and common epispastics, especially to the epigastrium; while I 
administered internally, if the stomach would retain it, chicken or mutton broth 
containing a very httle salt; and to relieve the thirst, nausea, or sense of burn- 
ing, ice and iced water in small quantities. I have repeatedly witnessed the best 
effects from the administration of animal broths in these cases, and I believe they 
are more likely to be retained on the stomach than any thing else. They are 
certainly better adapted to fulfil the important indications of relieving the irri- 
tation, while at the same time they sustain the strength, than any other articles 
within my knowledge. Stimulants, internally, will almost invariably excite vo- 
miting, and so far from rousing the patient, or giving him any real strength, 
only sink him the lower. 

In genera], I would remark, that the disease has been more mild and manage- 
able then in 1832; the cases have been more protracted, and not so suddenly 
fatal. The intemperate class, as usual, have suffered most; though a few tem- 
perate and highly respectable individuals have fallen victims. At present, a 
few deaths are occurring daily, and I should think it probable, that sporadic 
cases will continue to occur for some time. 

New York, Sept. 21s/, 1834. 

Twelve Cases of Poisoning by Arsenic in the Same Family. By W. G. RAivrsATj 
M. D. of Charleston, S. C— On Sunday, August 4th, I was requested by Dr. 
George Haig to visit with him a family composed of twelve coloured persons 
in Smith's Lane, who had sent for him in haste, as they were all seized with, 
vomiting immediately after dinner, which created much alarm. The account 
we received was, that having dined at 2 o'clock, all of them eat of fowl 
soup; they had taken very little of the soup, when they were seized with 
nausea, followed with vomiting; two of the children complained that the soup 
tasted bitter, and refused to eat it. Dr. George Haig saw them about an hour 
after they were taken sick, and suspecting from the aggravated symptoms that 
they were poisoned, and not being able to attend personally to so many, he 
sent for me, and requested my assistance. Dr. T. Y. Simmons was also sent 
for by the family, who kindly rendered his aid. 

I will proceed to give the notes on the cases separately. 

Case I. Rose Pensel, coloured girl, aged nineteen years, sanguineous tem- 
perament, was seized with vomiting, retching, and burning sensations in the 
stomach immediately after eating, which was followed by convulsions; dilata- 
tion of the pupils; cool skin; pulse 120, small, quick, and irregular; when the 
convulsions subsided, she complained of excruciating pains in the head and 
stomach. R. An emetic of sulph. zinc, assisted with large draughts of warm 
water, which vomited her freely; white of eggs beat up; sinapisms to legs; 
twelve ounces of blood from the epigastrium by cups; iced gum water, wine- 
glassful every fifteen minutes; ice applied to head. 8 o'clock, P. M. Has 
vomited but twice since last visit; skin not so cool; convulsions abated; ex- 
pressed much relief of pain in stomach from cups; much determination to head-, 



260 QUARTERLY PERISCOPE. 

stupor. R. Continue gum water and cold applications to head; wann fomen* 
tations to epigastric region. 

August 5ih, 6 o'clock, A. M. — Slept well during the night; skin warm; com- 
plained of much head-ache; delirious; pupils dilated; intolerance of light, eyes 
suffused; pulse small and quick, 120. R. Six ounces of blood from back of 
neck by cups; cold to head, and warm fomentations as far as knees by means 
of blankets, wrung out of hot water; 01. ricini, §ss. 1 o'clock, P. M. Has 
been quiet; does not complain of so much pain; skin comfortable; brain symp- 
toms greaty relieved; no operation from bowels. I^. Stimulating enema; con- 
tinue applications. 8 o'clock, P. M. Drowsy, sleeps much, with muttering; 
no operation from bowels. R. Small doses of sul. magnesia; continue appli- 
cations. 

6^A, 8 o'cloc'k, A. M. Did not sleep well; intellect confused; complains of 
dull pain in head; salts operated, stools black and offensive; pulse small and 
irregular, 112. JJ. Twelve leeches to neck; blister between shoulders; con- 
tinue sul. magnesia in small doses. 2 o'clock, P. M. Much better; bowels 
well evacuated; intellect clear; pulse regular, 100. 8 o'clock, P. M. Continues 
better; skin moist and comfortable; no dilatation of the pupils; pulse 96; blister 
has drawn well; ordered to be kept quiet. 

7ih. Has had a good night's rest; feels much better; complains of no pain; 
convalescent. The symptoms of this individual's case were the most aggra- 
vated, on account of her having eaten more of the soup than any of the others; 
the acute symptoms of the brain were much alleviated by the warm fomenta- 
tions applied to the inferior extremities as far as the knees. I recollect a re- 
mark made to me by Dr. S. Jackson, that in these acute affections of the brain, 
that the fomentations acted much more beneficially as a revulsive, than the 
practice of blisters to the extremities in such cases, as the cutaneous irritation 
of the blisters being easily transmitted to the brain, which is already the af- 
fected organ, was injurious. I am happy to say I have seen the truth of this 
remark fully verified. 

Case H. Margaret, sister to "Rose, aged seventeen years, was seized imme- 
diately after eating, with vomiting and burning pain in stomach, faintness, skin 
cool, pulse quick and small, no convulsions, intellect clear; her symptoms, 
which were not as violent as her sister's, were relieved by an emetic of zinc. 
Twelve ounces of blood from epigastrium by cups; warm fomentations to epi- 
gastrium; iced gum water frequently during the night. 

5^A, 7 o'clock] A. M. Has had a little sleep during the night; does not com- 
plain of any pain in stomach, but of much head-ache; intellect clear; bowels 
torpid; skin comfortable, and of the natural temperature; pulse 80. R. 01. 
ricini, ^ss. 6 o'clock, P. M. Feels much better; head relieved; bowels well 
evacuated; stools black and offensive; pulse natural, 7&. 

6th. Convalescent; swelling of the face, especially of the eyelids; joints of 
fingers much swollen. 

Case HI. Maria, aged six years, sister to the above, was attacked in like 
manner after eating a small portion of the soup; an emetic of zinc, with warm 
water, quickly relieved her. 

5th. Much better; no operation from bowels. R. 01. ricini. 

6th. Convalescent. 

Case IV. Margaret Wilson, aunt to the above, aged fifty years, plethoric, 
was severely attacked after eating, with vomiting and purging, burning pain 
in stomach, constriction across the chest, great arterial excitement, pulse slow, 
full, and irregular, difficult and painful micturition, stools black and very offen- 
sive, burning pain at the anus. R. Warm water, which evacuated the sto- 
mach well; six ounces of blood from epigastrium by cups, twelve ounces from 
arm; warm fomeijtations to epigastrium; iced gum water frequently. 

Sthf 7 o'clock, A. M. Had a little sleep; feels much relieved; purging and 
vomiting arrested; complains of no pain in stomach; pulse regular and soft; 
experiences much difficulty and pain in passing her urine; free discharge of 



i 



American Intelligence. 261 

blood from uterus during the night, which she says 5s a return of her menstrual 
discharge, although she has not had a return for five years; the discharge re- 
sembled the menstrual blood in appearances; complains of vertigo and head» 
ache. R. Pul. rhei. and cal. mag. fomentations to epigastrium and abdomen. 

^ih. Rested well all night; feels much better; burning when passing urine 
not so great; discharge continues, but in small quantities; head relieved; medi- 
cine operated well. 

7ih. Convalescent- slight discharge from uterus; swelling of face and joints. 
This case differs from the others in many of the symptoms, and points out 
clearly the different effects of the same substance on different constitutions^ 
this woman being very plethoric, the arterial system was most disturbed; the 
pulse, which in the other cases was quick and small, was in this case full and 
slow; the bowels were much affected; in the others they were torpid. The 
urinary organs and the uterus were also affected. Christison says urinary 
symptoms are seldom present, unless the lower bowels are likewise strangely 
irritated. 

Case V. Louisa Richardson, negro woman, aged forty years, delicate con^- 
stitution, was seized about an hour after eating with vomiting and violent retch- 
ing, faintness, burning pain in stomach, pulse small and quick; she was relieved 
by an emetic of zinc, with warm water drank freely; warm fomentations to 
epigastrium; iced gum water. 

5th. Rested badly; complains of no pain, but great weakness; pulse very 
small and quick; had three stools during the night, which were black and very 
offensive. R. 01. ricini, ^ss. 

6/A. P^eels much better; oil operated well; pulse more natural. 

7/A. Convalescent, attended with troublesome palpitation. 

Case VI. Ann, coloured girl, daughter to the above woman, aged eighteen 
years, was seized immediately after eating, with vomiting and retching, faint- 
ness, burning pain in stomach, pulse small and quick, skin cool, much head- 
ache. R. Twelve ounces of blood from epigastrium; emetic of zinc; iced guiia 
water; warm fomentations to epigastrium. 

Sth. Feels better; symptoms relieved; bowels torpid. R. 01. ricini. 

6/A. Convalescent, attended with swelling similar to the other cases, and 
also with sore throat. 

Case VII. Mary, sister to the above, coloured, aged fifteen years, was at- 
tacked immediately after eating, in a similar manner to her sister, and v/as re- 
lieved by the same treatment; her convalescence was attended with the usual 
swelling. 

Case VIII. Agnes, sister to the above, aged twelve years, remarked, after 
having taken a little of the soup, that it had a bitter taste, and refused to eat of 
it; she quickly vomited the httle she had eaten, and was relieved without any 
serious symptoms. 

Case IX. James, brother to the above, aged eight years, refused also to eat 
the soup, on account of its having a bitter taste; he was but slightly affected. 

Case X. Maria, coloured, aged five years, was attacked with vomiting and 
retching immediately after eating a little of the soup; she was relieved by an 
emetic and warm water drunk freely. 

Case XI. Mary Hamilton, coloured, aged thirty-five years, dehcate constitu- 
tion, also eat of the soup, and was violently attacked immediately after with, 
vomiting and painful retching, burning pain in stomach, pulse w^eak, quick, 
and irregular; no purging. R. Six ounces of blood from epigastrium; emetic; 
iced gum water; fomentations to epigastrium. 

Sill. Relieved; bowels torpid. R. 01. ricini. This woman was confined a 
few days before, and was in delicate health. 

Case XII. Ann, her daughter, aged four years, was also attacked with retch- 
ing and vomiting; was relieved by an emetic; warm fomentations to epigas- 
trium. 

The symptoms of poisoning by arsenic were evident and well-marked in 



262 QUARTERLY PERISCOPE. 

these cases. In reviewing- the cases in detail, we will find that violent irritation 
of the aUmentary canal, especially of the stomach, with faintness and prostra- 
tion, were the most prominent symptoms; in the case of Margaret Wilson, not 
only the whole alimentary canal was affected, but also the uterus and urinary 
passag-e; in this case the poison acted as a powerful emenagogue, causing a 
free discharge after a cessation of five years. " In many instances," says 
Bachmann,* "the urinary passages are affected, the patient being harassed 
with frequent, painful and difficult micturition, swelling of the penis, and pain 
in the region of the bladder, or if a female, with pain of the vagina and exco- 
riation of the labia." It has been a matter of dispute, whether any effect from 
the poison during the act of swallowing is perceived by the patient; there is 
no doubt, says the same author, "that in the way in which arsenic is generally 
given, with a criminal intent, namely, mixed with articles of food, it seldom 
makes any impression at all upon the senses during the act of swallowing." 
In the cases of Agnes and James, both of them complained of a bitter taste 
when eating, so much so, that they eat very little of the soup. The secondary 
symptoms in these cases were well marked. I have often seen the same swel- 
ling of the face and joints, which I have noticed in all the cases, follow the 
continued use of Fowler's solution. As regards the period of attack, the symp- 
toms came on in most of the cases immediately after eating. *'In some in- 
stances the sickness and faintness, particularly when the poison was taken in 
solution, have begun a few minutes after it was swallowed."f 

Treatment. — The stomach was freely evacuated by emetics of zinc and co- 
pious draughts of warm water, ** The use of the stomach pump," says Chris- 
tison, *♦ although it has been applied to cases of poisoning- by arsenic, does not 
seem to possess any advantage whatever over the natural efforts of nature, if 
seconded by copious draughts of liquids." Not believing in any antidote for 
arsenic, these were treated as cases of acute gastritis with signal benefit. The 
iced gum water sweetened, and given frequently, was very beneficial in calm- 
ing the irritability of the stomach, and allaying the inordinate thirst which 
existed. It is not necessary for me to say any thing as regards the beneficial 
effects of local depletion in gastritis, as the advantages arising from it are daily 
experienced. 

Chemical Analysis. — A portion of matter ejected from the stomach was car- 
ried to Messrs. Caullier and Harper, distinguished and highly deserving che- 
mists of this city, who, after a minute examination detected arsenic by two 
different tests; first, reduction by which the metallic ring was beautifully ex- 
hibited; the second was Scheele's green. 

It appeared on evidence at the trial, that a negro man, living on the same 
premises with these persons, and had had a quarrel with them a few days 
previous; on Sunday he went into the kitchen, and not seeing any persons near 
him, he deposited arsenic in the soup, a large quantity of which was found in 
his possession; he was found guilty and executed. 

Charleston^ July 241 h, 1834. 

Description of a New Form of the Stomach Pump. By P. B. Goddarb, M. D. 
of Philadelphia. — This pump consists of two parts, one of which I shall call the 
valve box, the other is an ordinary syringe, of good construction, to which the 
valve box is screwed when in use. 

The valve box is a cylinder of metal, containing ovoidal or egg-shaped cavi- 
ties, equally distant from the centre of the cylinder; at this point a pipe enters, 
which, when screwed on to the syringe, opens a communication between its 
cavity and these two cavities in the valve box. Near each end of the cylinder, 
a short and slightly conical tube projects laterally, to which a flexible tube is 
to be fastened, and which causes a communication between the flexible tube 
and the cavity in the valve box. Each of these cavities contain a bullet accu- 

• Bachmann on Poisoiu t Christison. 



dmerlcan Intelligence. 



2G3 



rately turned, so as to fit the orifices of the tubes, entering" into it, and acting- 
as a valve. It will be seen by reference to Fig". 1, (which represents a sec- 
tion of the valve box,) that if the valve box be held vertically, and the sy- 
ringe screwed on to it, the bullet in the upper cavity will fall upon the orifice 
of communication between it and the body of the syring-e, whilst the bullet ia 
the lower cavity, will in like manner lie upon the orifice of the tube leading- ex- 
ternally. If the lower tube be now immersed in water, and the piston of the 
syringe be drawn out, it will be evident that the body of the syringe will be 
filled with water from the lower tube. If now the piston be pressed home, the 
water will pass out of the upper tube; the bullet in the lower cavity preventing 
its escape there, just as the bullet in the upper one prevented the entrance of 
air before. It will then always pump water, or any other fluid, from the lower 
tube to the upper. 

If the position of the valve box be now reversed, and the end which was 
above be placed below, the bullets will fall by their own gravity into the oppo- 
site ends of the cavities, and the instrument will act as it did before, viz. pump- 
ing from the lower orifice to the upper, although the relative position of the 
tubes has been reversed. 

To use this instrument, the valve box must be held in nearly a vertical direc- 
tion. A long flexible tube being passed into the stomach, is attached to one of 
the short conical tubes, say the upper, and a short tube leading to a basin is 
then fastened to the lower one. The basin being filled with warm water, and 
the syringe put in action, the water will pass into the stomach and dilute the 
poison. When enough has passed in, the syringe is to be turned in the hand, 
so as to bring the tube down which was before above, without taking off the 
flexible tubes, or changing them in any way, and the syringe again put into 
action. The water will be pumped out of the stomach bringing the poison 
along with it. 

The following are the chief advantages of this instrument. It is perfectly 
simple in its construction, and not liable to get out of order. 

The directions for its use are easily understood, and as easily remembered. 

After the flexible tubes are once adjusted, no alteration is required until the 
operation is finished. 

When the instrument is once put in action, gallons of water may in a few 
minutes be passed through the stomach, thus washing away every trace of 
poison, and saving many a valuable life. 

Explanation of the Figures. 



Fig. 1, Section of the valve box. 
a a, Cavities for the bullets. 
h b. Bullet valves. 

c c, Tubes, to which are attached the flexible 
pipes. 
d, Female screw by which the valve box is at- 
tached to the syringe. 




Fig. 2. 



Fig. 2, Miniature view of the entire instrument, 
a, The syringe. 
by The valve box. 



Journal of the FranM'n Institute, April, 1834. 



264 QUARTERLY PERISCOPE. 

Introduction of Air into the Veins. By Benjamiis^ F. WiifG, M. D. (Read be- 
fore the Boston Society for Medical Improvement.) — I have selected for the 
subject of my communication this evening-, the introduction of air into ihe 
veins. My attention was first drawn particularly to the subject in consequence 
of having witnessed the death of an individual, which was supposed to have 
been caused by this accident while she was undergoing a surgical operation. 
Believing that as good an understanding of it might be obtained by interro- 
gating nature through a series of experiments, as by studying the different au- 
thors who have written upon it, I undertook the following experiments. 

Exp. I. — The external jugular vein of a full-sized rabbit was laid bare for 
some distance, and a branch of it selected for the insertion of a tube, that the 
current of blood through the principal vein should not be interrupted. By 
means of a small syringe the air was forced into the vein, and globule after 
globule was seen to enter the jugular and pass along with the blood, producing 
in the vicinity of the heart a slight gurgUng noise. This organ immediately 
testified its presence by violent action for the space of about one minute, when 
it suddenly ceased to act. The animal made a few convulsive struggles, utter- 
ed aery, gasped at intervals of some seconds, and expired. 

An examination of the body was made twenty minutes after death. The 
muscles contracted under the stimulus of the knife. The brain presented no 
uncommon appearance. Its blood-vessels were not engorged, nor was any air 
discovered in them. The lungs were of their ordinary appearance, filling the 
cavity of the thorax, but immediately collapsing on the admission of air. On 
laying open the pericardium, the coronary vessels of the heart were perceived 
much injected. The right auricle and ventricle, together with the vense cavse, 
were distended with air mingled with blood in a semi-coagulated state. In the 
left auricle was found a little blood with a small portion of air. The corres- 
ponding ventricle was entirely empty. 

The six succeeding experiments were tried upon other rabbits, varying the 
quantity of air from a volume equal to one to that of three fluid drachms. The 
results being similar to the one described, it appears unnecessary to state the 
particulars attending each case. I shall therefore pass on to the relation of some 
that were tried upon larger animals, where the quantity of air in proportion to 
their size could be more easily regulated. 

Exp. VIII. — Air was gradually thrown into the jugular vein of a small-sized 
sheep, in a manner similar to that described in Experiment I., until the quan- 
tity equalled the volume of a fluid ounce. The time occupied did not vary far 
from ten minutes. The gurgling noise noticed in the first experiment, slight 
difficulty of respiration, together with gentle struggles indicative of suffering, 
followed each movement of the piston forcing the air into the vein. After these 
symptoms subsided, the vein was secured and the animal released. It immedi- 
ately manifested a disposition to eat, sought its fellows, and mingled witli the 
flock. 

Exp. IX. — In this experiment double the quantity of air was used. The 
symptoms differed only in intensity. They speedily subsided, and the sheep, 
after being released, could not be distinguished by any peculiarity of manner. 

Exp. X. — A volume of air equal to three fluid ounces was injected with such 
rapidity, that the globules were seen constantly passing through the jugular 
vein towards the heart. In this case much disturbance occurred. The animal 
evinced much suffering, the struggles approached convulsions, and the respi- 
ration became very difficult. After an interval of fifteen or twenty minutes 
of doubt as to the result, the symptoms gradually subsided. The sheep, 
when loosed from its bonds, could scarce support itself, but at length it walked 
away. 

On the following day the three sheep subjected to experiments presented no 
peculiarity of manner. One was slaughtered in the usiial way. No air was 
seen to escape with the blood, nor was any coagulum found in the heart. The 
lungs were of their ordinary appearance. In fact, I could not discover any 



*dmerican Intelligence. 265 

difference between those that were subjected to the experiments and those 
that were not. 

Exp. XI. — In this instance the precise quantity of air could not be determin- 
ed. It amounted at least to a volume equal to six fluid ounces. It was inject- 
ed as expeditiously as possible, and its effects were immediately apparent. The 
heart palpitated violently a short time, then suddenly ceased to convey any 
sound to the ear; convulsions and gaspings were soon followed by a suspension 
ofall signs of animation. The jugular vein that was dissected of its integu- 
ments became enormously distended, and the contents apparently stagnant. 
Under the conviction that the animal had become a victim to the experiment, 
the jugular was freely opened, and blood mingled with air was freely discharged. 
After a considerable quantity was evacuated, the sheep again respired, and the 
heart resumed its action. It was finally killed by opening the carotid artery. 
In this case some frothy blood was found in the right side of the heart, and the 
muscles presented an unusual redness, in consequence of a retention of blood 
in the capillary vessels. 

The result of the eighth, ninth, and tenth experiments, show that air when 
admitted into the veins, although producing derangement in the functions, yet 
does not necessarily cause immediate death; but that the symptoms will gradu- 
ally subside, and the organs resume their ordinary functions, provided the quan- 
tity is not too great in proportion to the size of the animal. But when this is 
carried beyond a certain point, the seven first experiments show as clearly that 
death will ensue. The last experiment may be considered doubtful in its 
effects: till, until the opening of the jugular, the symptoms were as strongly 
marked as in the cases where death was undoubtedly caused by the air. 

By reference to these experiments it will be seen, as would naturally be In- 
ferred, that the first evidence of the presence of air is disturbance in the heart, 
increasing until its action is entirely suspended, — not by a gradual diminution 
of its power, rendering the pulsations weaker and weaker, but suddenly 
stopped in its high tone of action. Difficult respiration succeeds the tumultu- 
ous action of the heart, and increases to gasping at lengthened intervals, until 
this function also ceases. The muscular system is, to all appearance, at first 
only excited to increased action by tlie pain endured, nor does this action differ 
from that which is testified by the animal when an incision is made preparatory 
to the experiment until the animal approaches the agonies of death, when it 
becomes universally spasmodic. 

It is necessary for the explanation of these vital phenomena, to suppose that 
the air arrives at each organ before any aberration of function is manifested — or 
cannot they be more satisfactorily accounted for, by referring the first impres- 
sion to the heart, where we know the air arrives, and the other effects to the 
functional dependence or sympathetic relation that exists between the heart, 
lungs, and brain? Can we not suppose that the air impairs tlie power of 
circulation, first by distending the heart with its own volume, and secondly by 
causing an imperfect closure of the valves, and thus permitting a reflux of 
blood at each contraction of the ventricle, which causes in its turn an increased 
disturbance, until it goes beyond the power of reaction to overcome? 

I am av/are the subject deserves a more varied and extensive course of ex- 
periments; but as circumstances do not permit me to continue my researches 
at present, I must beg leave to offer you these first fruits of my labour. — 
Boston Med. and Surg. Journ. May 14th, 1834. 

Luxation of Dentatus on Third Vertebra of the Neck. — The following Interest- 
ing example of this is related by Dr. A. J. Spencer, of Ticonderoga, in our 
cotemporary the Boston Med. Surg. Journ. Vol. X. No. 11. 

E. D., aged 50, a man of hale constitution and robust, in making an effort to 
scale a board fence, was suddenly precipitated backwards to the ground; striking 
firstupon the superior and anterior portion of the head, which luxated the den- 

No. XXIX. —November, 1834. 23 



266 QUARTERLY PERISCOPE. 

tatus anteriorly on the third cervical vertebra. He was at length discovered, and 
taken in, (as the patient said,) after he had lain nearly an hour, in a condition 
perfectly bereft of voluntary motion; but being* present I did not even suspect 
that the power of sensation was also gone, until the patient, (whose speech re- 
mained almost or quite perfect, and who was uncommonly loquacious at that 
time,) said, did he not know to the contrary, he should think he had no body. 
His flesh was then punctured, and sometimes deeply — even from the feet to the 
neck; but the patient gave no evidence of feeling, and when interrogated, an- 
swered that he felt nothing; "and," added he, "I never was more perfectly 
free from pain in my life," but he remarked that he could not live, and accord- 
ingly sent for his family, twelve miles distant, and arranged all his various con- 
cerns in perfectly a sane manner. 

The head was thrown back in such a position as to forbid his seeing his body. 
The pulse were much more sluggish than natural. Respiration and speech but 
slightly affected, but were gradually failing; but he could articulate- distinctly 
until within a few minutes before his death. All the senses of the head re- 
mained quite perfect to the last. He died forty-eight hours after the fall. 

Repeated attempts were made to reduce the dislocation, but the transverse 
processes had become so interlocked that every effort proved abortive. There 
was, undoubtedly, in this case, a perfect compression of the spinal marrow, 
which prevented the egress of nervous influence from the brain, while the 
pneumogastric nerve remained unembarrassed. 

Case of Puberty and Pregnancy in a Girl of Ten Years of Jge. — The follow- 
ing remarkable instance of this is related by Dr. D. Rowlett, of Kentucky, in 
our cotemporary, the Transylvania Journal of Medicine for October, 1854. 

*' Sally Deweese, daughter of John Deweese, was born in Butler county, 
Kentucky, on the fth of April, 1824. She was of the ordinary size, but her hips 
and breasts began to grow rapidly in a few weeks after she was born, and at 
twelve months of age she began to menstruate, and her hips and breasts had 
become so large as to be the objects of common remark; and as she took no 
pains to conceal her conditionj her menstruating so young, became a fact of 
public notoriety, which continued regular till some time in the year 1833, when 
she became pregnant, and on the 20t!i day of April, 1834, she was delivered of 
a healthy female child, weighing seven and three-fourth pounds. Thus, at the 
age of ten years and thirteen days, she became the mother of a child of ordi- 
nary size; which, however, refused to suck her, and has been so far raised by 
the bottle. It is as healthy as is usual for children to be when raised from the 
bottle, and at the time of taking these notes it weighed eight and three-fourth 
pounds, and its mother weighed one hundred pounds. She was four feet seven 
inches high and had the countenance of a girl not exceeding her in years, but 
is as intelligent as girls generally are at her age. 

" She was the fifteenth child her mother had given birth to, and was born when 
her mother was forty-five years of age. There had been no previous case of 
early puberty, or premature old age in either the family of the father or mother. 

" Her father lived in Butler county until she was two years old, and then re- 
moved to the place on which he now lives, in Hickman county, one mile south 
of Mayfield's Creek, and ten miles east of the Mississippi river, in latitude 36° 
59' N. ; but I presume that latitude nor atmosphere has had any influence in this 
truly, (to me,) astonishing case. I think it is an over-match for the case of the 
Swiss girl spoken of by Haller." 

Ointment to Allay the Irritation of Hsemorrhoidal 2^umours. — The follow- 
ing ointment is recommended by Dr. Gebdiis'gs in our esteemed cotemporary, 
the North American Archives of Medical and Surgical Sciences, No. 1, as affording 
great relief to the irritation of hsemorrhoidal tumours: — R. Pulv. carb. plumbi. 
§ss. ; sulph. morph. gr. xv. ; ung. stramon. ^j.; ol. olivar. q. s. Ft. ung. part. 
applicand. 



American Littlligence. 267 

Powdered opium to the amount of a drachm may be substituted for the mor- 
pTiia, and if the dry white lead is not at hand, that which is ground in oil for the 
^se of painters may be advantageously substituted. Sometimes a drachm of 
powdered galls may be added. 

Contribution to the History of Vaccination. By the Editor. — The following 
fact, illustrative of the value of the Jennerian discovery, seems worth recording-. 
A granddaughter of Mrs. M.'s was attacked in April, 1833, with small-pox, wliich 
ran its course and terminated favourably. About six weeks afterwards, viz. on 
the 1st of .Tune, Mrs. M.'s daughter and grandson, (residing in the same house 
with the first patient,) the former aged thirty-five, the latter eighteen, were 
attacked with head-ache and fever, followed on the third day by an eruption 
which presented the ordinary features of varioloid, and ran the usual course of 
that disease. The eruptive fever in the grandson was very mild, but three 
pocks appeared on his face, and proportionally few on his body. On the tenth 
day he had sufficiently recovered to go abroad. The daughter had severe 
head-ache and high eruptive fever; had forty-three pocks on her face, and a 
proportional number on the rest of her person. 

AVhen children, the grandson had been vaccinated, and the dauglder inno- 
culated. The latter had the small-pox at that time, (as the mother informed me,) 
pretty severely, had several pocks; and subsequently she had had chicken-pox. 

B ill of Mortality of Philadelphia for the year 1^^'^. With remarks, by G. Emer- 
SON, M. D.— The Philadelphia Bill of Mortality for the year 1833, compared with 
that of the previous year, shows a diminution in the deaths of no less than 2,259. 
Even when allowance is made for the mortality from the epidemic cholera of 
1832, the amount from general diseases in 1833 falls short 1311. 

There is a diminution in the mortality from every particular disease specified 
as contributing largely to the general mortality, with the exception of small- 
pox and varioloid, the deaths from which have increased within the past year. 

The rate of diminution is particularly striking under the heads of Fever, 
Bowel Complaints, Inflammations and Measles, as will be evident from the fol- 
lowing comparative statement: — 

Deaths from Fevers, - = Year 1833, - - - 1832. 

viz. Of all designations - - 360 - - - 768 

Puerperal - - 32 8 

Eruptive - - 4 307 - 315 

Scarlet - - 61-97 ■ 

..^ = . 453 

263 263 

Diminished mortality in the last year . - » . = 190 

The deaths from bowel complaints with the periods of life when they took 
place, stand as follows: — 



Under 1 year. 


lto2 


2 to 5 


5 to 20 


Children. 


Adults. 


Totals 


Diarrhoea - - - 25 


- 11 


- 6 


- 4 


46 - 


41 - 


87 


Dysentery - . 4 


- 4 


- 3 


. 4 


15 ^ 


29 - 


44 


Cholera morbus \ . ^^ 
^nd infantum 5 ^^^ 


- 59 


- 6 


- 


197 - 


9 - 


206 



161 74 15 8 258 79 337 

Bowel complaints in 1831 . , , - - - 522 

do. do. 1832 (exclusive of epidemic cholera) 689 

do. do. 1833 337 



268 QUARTERLY PERISCOPE. 

The number of deaths from the phlegmasia in the two last years are also 
strongly contrasted. The deaths from the respective inflammations were as 
follows: — 

Year 1833. 1832. 

Lungs 166 - - 225 

Chest 17 . . 19 

Heart 2 - - 4 

Windpipe - 3 - - 

Total in the cavity of the chest ... 188 - - 248 

Stomach 48 - - 41 

Bowels 135 - - 125 

Liver 18 - - 21 

Kidneys 2-- 1 

Bladder ....... l . . 1 

Total in the cavity of the abdomen - - 204 - - 189 

^^Z ■ ■ ■ ■ ^U . . 74 . . 102 

bpme - - - - 23 

Various 7-. 49 

473 588 
473 

Diminution in 1833 115 

Year 1833. 1832. 

Dropsy 80 - • 115 

do. in the head 170 - - 187 

do. in the breast 52 - - 62 

302 - - 364 

The mortality from consumption and the other most fatal diseases compared 
with those of the preceding year stand thus: — 

Year 1833. 1832. 

Consumption - - 650 - - 681 

Convulsions 266 - - 342 

Small-pox 156 - - 37 

Varioloid 12 - - 6 

Measles 1 - - 118 

Scarlet fever 61 - - 307 

Croup 95 - - 110 

Bronchitis 37 - - 97 

Apoplexy 3 55 - - 78 

Hooping-cough 53-. 58 

Births. 1833 1832 

Males - 3,840 - - 3,834 

Females 3,802 - - 3,419 

7,642 - - 7,253 

Deaths 4,440 - - 6,699 

Difference between the births and deaths - 3,202 - - 554 



Jlmerican Intelligence. 



269 



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There were 406 returns received at the Health Office, of persons who died 
in the Aims-House of the City and Districts during- the year; 478 people of 
colour are included in the total number of deaths. 

^ Ag-reeable to returns made at the Health Office and collected from 157 Prac- 
titioners of Midwifery, there have been born in the City and Liberties, from the 
1st of January, 1833, to the 1st of January, 1834, 3,840 male, and 3,802 female 
children, making the total number of births 7,643, leaving- a difference between 
the births and deaths of 3,202. 



Deaths in each Month of the above period. 



January 

February 

March - 

April 

May 

June 

July 

August 

September 

October 

November 

December 



Adults. 


Children. 


Total. 


203 


192 


395 


152 


168 


320 


180 


186 


366 


175 


148 


323 


178 


179 


357 


141 


209 


350 


224 


362 


586 


162 


240 


402 


167 ■ ■ 


180 


347 


199 


161 


360 


166 


149 


315 


152 


167 


319 



2099 2341 4440 

By order of the Board of Health, 

WM. A. MARTIN, Clerh, 
Health Offiee, Philadelphia, January 1st, 1834. 



/Salivation Arrested hy Emesis. — Dr. Ezra Read, of Cincinnati, has com- 
municated to our cotemporary, the Western Medical Gazette, (August, 1834,) 
five cases of salivation promptly arrested by emesis. The emetic employed in 
three of the cases was ipecacuanha. 

Paxton's Anatomy. — The second Volume of the Introduction to the Study 
of Human Anatomy, by James Paxton, with additions by Winslow Lewis, Jr. 
M. D. has lately been issued from the press of Messrs. Allen and Ticknor, of 
Boston. This is a very useful elementary work; the text is concise and perspi- 
cuous, and is illustrated by numerous, and for the most part well-executed 
wood cuts. The manner in which this work has been " got up" is highly cre- 
ditable to the publishers, and v/orthy of all praise. 

University of Pennsylvania. — We are happy to announce the appointment of 
WitLiAiMc P. Dewees, M. D. to the chair of Obstetrics and Diseases of Women 
and Children in the University of Pennsylvania in the place of Thomas C. James, 
M. D. resigned. 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



No. XXX.— February, 1835. 24 



COLLABORATORS. 



Jacob Bigeloav, M. D. Professor of 
Materia Medica in Harvard Univer- 
sity, Boston. 

Edward H. BAKToif, M. D. of New 

Orleans. 
ll^NUT Bronsobt, M. D. of Albany, New 

York. 
Reynei Coates, M. D. of Philadelphia. 
Walter Channing, M. D. Professor of 
Midwifery and Legal Medicine in 
Harvard University, Boston. 
N. Chapman, M. D. Professor of the 
Institutes and Practice of Physic and 
Clinical Practice in the University of 
Pennsylvania. 
John Hedman Coxe, M. D. Professor 
of Materia Medica and Pharmacy in 
the University of Pennsylvania. 
D. Francis Condie, M. D. of Phila- 
delphia. 
William C Daniell, M. D. of Savan- 
nah, Georgia. 
William P. Dewees, M. D. Profes- 
sor of Midwifery in the University of 
Pennsylvania. 
S. Henrx Dickson, M. D. Professor of 
the Institutes and Practice of Medicine 
in the Medical College of the state of 
South Carolina. 
Benjamin W. Dudley, M. D. Profes- 
sor of Anatomy and Surgery iri Tran- 
sylvania, University. 
HoiJLEY DuNGLisoN, M. D. Profcssor of 
Materia Medica, Therapeutics, Hy- 
giene, and Medical Jurisprudence, in 
the University of Mary land. 
GoTJVERNEuu Emerson, M. D. of Phila- 
delphia. 
Paul F. Ete, M. D. Professor of Sur- 
gery in the Georgia Medical College. 
John W. Francis, M. D. Late Profes- 
sor of Obstetrics and Forensic Medi- 
cine in Rutgers Medical College, New 
York. 
W. W. Gerhard, M. D. of Philadelphia. 
William Gibson, M, D. Professor of 
Surgery in the University of Pennsyl- 
vania. 
R. E. GmT-FiTH.,M. B. of Philadelphia. 
E. Hale, M. D. of Boston. 
George Kayward, M. D. Professor of 
the Principles of Surgery and Clini- 



cal Surgery in Harvard Universityj 
Boston. 
William E. Horner, M. D. Professor 
of Anatomy in the University of 

Pennsylvania. 

David Hosack, M, D. Late Professor 
of the Instiiides and Practice of Medi- 
cine in Rutgers Medical College, New 
York. 

Ansel W, Ives, M. D. of New York. 

Samuel Jackson, M. D. Assistant to the 
Professor of the Institutes and Practice 
of Medicine and Clinical Practice in 
the University of Pennsylvania. 

Samuel Jackso::^, M. D. of Northum- 
berland, Pennsylvania. 

John George Morgan, M. D. PrO" 
fessor of the Principles and Practice 
of Surgery in Geneva College, New 
York. 

Valentine Mott, M. D. Professor of 
Pathological and Operative Surgery 
in the College of Physicians and Sur- 
geons, New York. 

James Moultrie, Jr. M. T). Professor 
of Physiology in the Medical College 
of the state of South Carolina. 

Reuben D. Mussey, M. D. Professor 
of Anatomy and Surgery in Hart- 
mouth College, New Hampshire. 

T. D. Mutteh, M. D. of Philadelphia. 

R. M. Patterson, Til. D. Professor of 
Natural Philosophy in the University 
of Virginia. 

Philip Syng Phystck, M. D. Profes- 
sor of Anatomy in the University of 
Pennsylvania. 

Thomas Sewall, M. D. Professor of 
Anaiomy and Physiology in the Co- 
lumbian College, District of Columbia. 

Ash BEL Smith, M. D. of Salisbury, 
North Carolina. 

A. F. Vache, M. D. 'of New York. 

John Ware, M. D-. Jtssistajit Professor 
of the 'Theory and Practice of Physic 
in Harvard University, Boston. 

John C. Warren, M. D. Professor of 
Anatomy and Surgery in Harvard 
University, Boston. 

Thomas H. ^VRIGHT, M. D. Physician 
to the Baltimore Aims-House Infir- 
mary. 



I 



EDITOR— Isaac Hays, M. D. 



TO READERS AND CORRESPONDENTS, 



Communications have been received from Drs. Reynolds, Somervail, 
Malone, Smart, Elkingtok, Rodkigue, and Williams. 

Several arti-cles intended for this No. have been excluded for want of room, 
although we have exceeded our limits by twelve pages? among others, a notice 
of Holland's Principles of Medicine. 

The following works have been received: — 

The Anatomy and Physiology of the Liver. By Francis Kiernan, Esq. 
Member of the Royal College of Surgeons; late Teacher of Anatomy. From 
the Philosophical Transactions. London, 1833. (From the author.) 

On some Points connected with the Pathology of Puerperal Fever. By 
Alexander John Hannat, M. D. Member of the Faculty of Physicians and 
Surgeons, Glasgow; Lecturer on the Theory and Practice of Physic. Glasgow, 
1827. (From the author.) 

Considerations sur la Nature et le Traitment de Cholera Morbus, Suivies 
d'une Instruction sur les Preceptes Hygieniques contre cette Maladie; par le 
Chevalier J. R. L. De Kerckhove bit De Kirckhoff, M. D. &c. &c. &c. 

Anvers, 1833. (From the author.) 

On the Influence of Atmosphere and Locality; Change of Air and Climate; 
Seasons; Food; Clothing; Bathing; Exercise; Sleep; Corporeal and Intellectual 
Pursuits, &c. &c. on Human Health, constituting Elements of Hygiene. By 
RoBLEr Dunglison, M. D. Professor of Materia Medica, Therapeutics, Hy- 
giene, and Medical Jurisprudence in the University of Maryland, &c. &.c. Phi- 
ladelphia, Carey, Lea & Blanchard, 1835. (From the author.) 

Systematical Anatomy, or Human Organography, in Synoptical Tables, with 
numerous Plates. For the use of Universities, Faculties and Schools of Medi- 
cine and Surgery, Acadenaies of Painting, Sculpture, and the Royal Colleges. 
By the Chevalier J. Sarlandiere, M. D. Member of the Royal Academy of 
Madrid, and of the Medical Society of Emulation of Paris, &c. &:c. Translated 
from the French by W. C. Roberts, M. D. ;Member of the Medical Society of 
the City and County of New York. New York, lithographed and published by 
J. & E. Bisbee, 116, Franklin street, New York, 1835. (From the publishers.) 

The Principles of Diagnosis. By Marshall Hall, M. D., F. R. S. Second 
edition, entirely re-written. New York, D. Appleton & Co. 1835. (From the 
publishers.) 

An Address introductory to a Course of Lectures delivered in Clinton Hall, 
New York, November, 8th, 1834. By Gunning S. Bedford, M. D. Lecturer 
on Obstetric Medicine, and the Diseases of Women and Children. Second 
edition, New York, 1835. (From the author.) 



280 TO READERS AND CORRESPONDENTS. 

An Introductory Lecture delivered to the Medical Class of the University of 
Virginia at the Commencement of the Course on Anatomy, Physiology, and 
Surg-ery. By Augustus L. Wauner, M. D. Professor of Anatomy, Physiology, 
and Surgery. Published by the Class. Charlottesville, 1834. (From the 
author.) 

Outlines of Human Physiology; designed for the Use of the Higher Classes 
in Common Schools. By George Hatward, M. D. Boston, 1834, Marsh, 
Capen & Lyon. (From the author.) 

A Treatise on Tubercular Phthisis, or Pulmonary Consumption. By James 
Clark, M. D., F. E. S. Physician in Ordinary to their Majesties the King and 
Queen of the Belgians. From the Cyclopedia of Practical Medicine. London, 
1834. (From the author.) 

Physiologisch-chirurgische Beobachtungen bei Cholera-kranken. Von J. F. 
DiEFFEKBACH, D. M. & C. &c. &c. (From Dr. Von dem Busch.) 

A catalogue of the officers and students of Dartmouth College, October, 
1834. Newport, N. H. 1834. 

A Practical Treatise on Medical Jurisprudence, with so much of Anatomy, 
Physiology, Pathology, and the Practice of Medicine and Surgery, as are es- 
sential to be known by Members of Parliament, Lawyers, Coroners, Magistrates, 
Officers in the Army and Navy, and Private Gentlemen; and all the Laws re- 
lating to Practitioners; with Explanatory Plates. By J. Chitty, Esq. Barrister 
at Law. First American edition, with Notes and Additions adapted to American 
Works and Decisions. Part I. Carey, Lea & Blanchard, 1835. (From the pub- 
lishers.) 

De Thalamo et origine Nervl Optici in Homine et Animalibus Vertebratis. 
Auctor S. A. W. Stein. Haunize, 1834. (From Dr. Otto.) 

Dissertatio de EfFectibusIodii in Organismum Humanum usuque ejus Medico. 
Auctor F. A. Uldall. Hauniae, 1833. (From the author.) 

De Inflammatione Corneae Transparentis Scrofulosa. Auctor F. F. Mourier. 
Haunise, 1833. (From Dr. Otto.) 

De Dentitione Infantili cum Adjuncta Disquisitione de Spasmis et Antispas- 
modicis. Auctor F. A. Uldall. Haunise, 1833. (From Dr. Otto.) 

Medico-Chirurgical Transactions, Vol. XVI. Part H. and Vol XVII. (From 
the Medico-Chirurgical Society of London.) 

A Treatise on the Urethra; its Diseases, especially Stricture, and their Cure. 
By Benjamin Phillips, author of a Series of Experiments made to Demonstrate 
that Arteries may be obliterated without Ligature, Compression, or the Knife. 
London, 1832. (From the author.) 

The substance of a Lecture designed as an Introduction to the Study of 
Anatomy, considered as the Science of Organization; and delivered at the re- 
opening of the School, founded by the late Joshua Brooks, Esq. in Blenheim 
street, October 1st, 1833. By Thomas King, M. D. Member of the Royal Col- 
lege of Surgeons; Surgeon to his Excellency the French Ambassador; Lecturer 
on Anatomy and Surgery, &c. 8cc. London, 1834. (From the author. J 






TO READERS AND CORRESPONDENTS. 281 

The Sphygmometer; an Instrument which Exhibits to the Eye the entire 
Action of the Arteries; the usefulness of this Instrument in the Study of all 
Diseases; Researches on the Diseases of the Heart, and on the Means of Dis- 
criminating them. A memoir presented to the Institute of France. By Dr. J. 
HERissoii, of Paris. Translated from the French, by Joseph G. Nakckess. 
Griggand Elliot, 1835. (From the translator.) 

The Edinburgh Medical and Surgical Journal for July and October, 1834. 
(In exchange.) 

The Medico-Chirurgical Review, for July and October, 1834. (In ex- 
change.) 

The Medical Quarterly Review, forOctober, 1833, January, April, and July, 
,1834. (In exchange.) 

The London Medical Gazette, for October and November, 1834. (In ex- 
. change.) 

Gazette Medicale de Paris, May, June, July, August, 1834. (In exchange.) 

Annales de la Mddecine Physiologique, March, April, May, June, 1834. (In 
exchange.) 

Revue Medicale, May, June, July, 1834. (In exchange.) 

Journal Hebdomadaire des Progr^s des Sciences et Institutions M^dicales, 
•May, June, July, August, 1834. (In exchange.) 

Journal des Connaissances Medico-Chirurgicales, June, July, August, 1834. 
(In exchange.) 

La Lancette Francaise, Gazette des Hopitaux Civils et Militaires, May, June, 
July, August, 1834. (In exchange.) 

Journal de Pharmacie et des Sciences Accessoires, May, June, July, August, 
1834. (In exchange.) 

Medicinisch-Chirurgische Zeitung, May, 1834. (From Dr. Vom dem Busch.) 

Bibliothek for Lxger, Nos. 2 and 3, 1834. (In exchange.) 

Magazin der Auslandischen Literatur der Gesammten Heilkunde, &c. He- 
rausgegeben von Dr. G. H. Gebson und Dr. N. W. Julius, July, August, Sep- 
tember, October, 1834. (In exchange.) 

The North American Archives of Medical and Surgical Science, for Novem- 
ber, December, 1834, and January, 1835. (In exchange.) 

The Boston Medical and Surgical Journal, Vol. XT. No. 12 to 21, inclusive. 
(In exchange.) 

The Western Journal of the Medical and Physical Sciences, October, 1834. 
(In exchange.) 

Western Medical Gazette, for October, December, 1834. (In exchange.) 

The Medical Magazine, November and December, 1834, and January, 1835. 
(In exchange.) 

24* 



282 



TO READERS AND CORRESPONDET^TS. 



Authors of new medical books, desirous of having* them reviewed or noticed 
in this Journal at the earliest opportunity, are invited to transmit to the Editor 
a copy as soon after publication as convenient, when they will receive prompt 
attention. Under ordinary circumstances, very considerable delay is caused by 
the circuitous routes through which they are received. 

Papers intended for publication, should be sent, free ofexpense^ as early after 
the appearance of the Journal as possible, in order to be in time for the ensuing 
number. Such communications should be addressed to " Caret, Lea & Blan- 
CHABD, Philadelphia, for the Editor of the American Journal of the Medical 
Sciences." 

All letters on the business of the Journal to be addressed exclusively to the 
publishers. 



CONTENTS 



ORIGINAL COMMUNICATIONS. 

ESSAYS. 

Akt. Page, 

I. Obscure Pericarditis — Dilatation of the Heart — Peculiar Species of Tu- 
mour in the Right and Left Ventricles, and Right Auricle — (Edema of 
the Fauces and Larynx, and Glottis — Death from Suffocation. By Samuel 
Jackson, M. D. Assistant to the Professor of the Institutes and Practice 
ofMedicine and Clinical Practice in the University of Pennsylvania. [With 
a coloured Plate and two wood-cuts] 289 

IL On the Mechanism of some Diseases of the Sympathetic Nerve. By 
W. W. Waddel, M. D. [Communicated by Professor Dickson, of Charles- 
ton, S. C] 299 

IIL Reports of Cases treated in the Medical Wards of the Pennsylvania 
Hospital. [Part 1st. Typhus and Remittent Fevers.] By W. W. Gerhard, 
M. D. Resident Physician - 320 

IV. Report of Cases Treated in the Surgical Wards of the Pennsylvania 
Hospital. By T. S. Kirkbride, M. D. Resident Physician - - 342 

V. Remarks on the Medicinal Properties and Effects of Prussiate of Po- 
tash; or Ferro-Cyanate of Potassa. By Burleigh Smart, M. D. of Kenne- 
beck, Maine --. 362 

VI. Cases of Midwifery. By John P. Harrison, M. D . of Louisville, Ken- 
tucky - - - - 366 

VII. Observations on Lepra and Psoriasis. By C. W. Pennock, M. D. 274 

VIII. On the Influence of Vaccination in counteracting the effects of Small- 
pox Contagion. By William Browne, M. D. of Fredericksburg, Va. 399 

IX. Case of a Child with Imperforated Anus, and Malformation of the Intes- 
tine. By John H. Steel, M. D. of Saratoga Springs, New York. [W^ith a 

Wood-cut] 404 

X. Accidental Occlusion of the Vagina, forming an obstacle to delivery. 
By C. Hoillemin, M. D. P. of Aux Cayes, Hayti. (Communicated in a 
letter to the Editor) - 407 

REVIEWS. 

XI. Researches on the Pathology and Treatment of some of the most Impor- 
tant Diseases of AY omen. By Robert Lee, M. D., F. R. S.; Physician-Ac- 
coucheur to the British Lying-in Hospital, and the Saint Mary-Le-Bone 
Infirmary; Lecturer on Midwifery in the School of Webb street. London, 
.1833, pp. 220, 8vo. - - - - - - „ .. .= 409 



284 CONTENTS. 

Abt. Fagb. 

XII. On the Influence of Atmosphere and Locality; Change of Air and Cli- 
mate; Seasons; Food; Clothing"; Bathing; Exercise; Sleep; Corporeal and 
Intellectual pursuits, &c. &c. on Human Health, constituting Elements of 
Hygiene. By Robley Dunglison, M. D. Professor of Materia Medica, 
Therapeutics, Hygiene, and Medical Jurisprudence in the University 
of Maryland, &c. &c. Philadelphia, Carey, Lea and Blanchard, 1835, 
pp. 514 424 

BIBLIOGRAPHICAL NOTICES. 

XIII. The Anatomy and Physiology of the Liver. By Francis Kiernan, 
Esq. R. C. Surgeons, &c. From the Philosophical Transactions. London, 

1833, 4to. pp. 60, plates iv. 442 

XIV. Clinical Lectures in the Manchester Royal Infirmary. By Edward Car- 
butt, M. D. ** Nullius addictus jurare in verba magistri." London, 

1834. 8vo. pp. 407 - - 445 

XV. Handbuch der Allgemeinen Therapie zum Gebrauch bei Seinen Vor- 
lesungen. Von Dr. Johann Wilheim Heinrich Conradi, Kbnigl Grossbri- 
tannisch. Hannoverschem Hofrathe, Professor der Medicin zu Gottengen, 
der Konigl. Gesellschaft der Wissenschaften daselbst und Mehrerer 
gelehrten -Gesellschaften Mitgliede. Cassel, 1833, 8vo. pp. 155. 

Manual of General Therapeutics, for the use of his Pupils. By John 
William Henry Conradi, &c. &c. ---..--- - 45.2 

XVI. Researches on some points of the History of Chorea in Children. 
By M. Rufz, Resident Physician at the Hospital for Children, at Paris. 
From the Archives Generales, February, 1834 . . - . 456 

XVn. Recherches Medico-Legales, sur I'Incertitude des Signes de la Mort, 
les Dangers des Inhumations Precipitees, les Moyens de Constater.les 
deces et de Rappeler a la vie ceux qui sont en etat de mort Apparente. 
Par M. Julia de Fontenelle, Professeur de Chimie Medicale, &c. &c. &c. 
Paris, 1834, pp. 352, 8vo. 458 

XVIII. Organon der Heilkunst. Von Samuel Hahnemann, "Aude Sa- 
pere." ,FUnfte verbessert und vermehrte Auflage, mit dem Bildnisse-des 
Verfassers. Dresden, und Leipsig, 1833, 8vo. pp. 304. 

Organon of Medical Science. By Samuel Hahnemann, " Aude Sapere." 
Fifth improved and augmented edition, with the portrait of the author. 
Dresden and.Leipsic, 1833. 

The Homseopathic Medical Doctrine, or *' Organon of the Healing Art," a 
new System of Physic. Translated from the German of S. Hahnemann, 
by Charles H. Devrient, Esq. with notes by Samuel Stratten, M. D. 
Dublin, 1833, 8vo. pp. 332 460 

XIX. Outlines of Human Physiology; designed for the Use oF the Higher 
Classes in Common Schools. By George Hayward, M. D. Boston, 
1834, 12mo.,pp. 217 - - - - 463 

XX. Medicinalbericht des Konigl. Preuss. Medicinal-Collegiums derPro- 
vinz Sachsen, fur das Jahr 1830. Zusaramengestellt von Dr. August 
Andreae, Konigl. Medlcinalrathe und Lehrer an der Med. Chir. Lehran- 

jsanstslt zu Magdeburg. Magdeburg^ 1831. 12mo. pp 96. 



CONTENTS. 



285 



464 



467 



Abt. Page. 

Medical Report of the Royal Prussian College of the Province of Saxony 
for 1830. Compiled by August Andreae, M. D. &c. 

XXI. Chemistry, Meteorology, and the Function of Digestion, considered 
with reference to Natural Theology. By William Prout, M. D., F. R. S.; 
Fellow of the Royal College of Physicians. Philadelphia, Carey, Lea & 
Blanchard, 1834, 12mo. pp. 307 

XXII. A Practical Treatise on Medical Jurisprudence, with so much of Ana- 
tomy, Physiology, Pathology, and the Practice of Medicine and Surgery, 
as are essential to be known by Members of Parliament, Lawyers, Co- 
roners, Magistrates, Officers in the Army and Nav}', and Private Gentle- 
men, and all the Laws relating to Medical Practitioners with Explanatory 
Plates. By J. Chitty, Esq. Barrister at Law. First American edition, 
with notes and additions, adapted to American works and Judicial deci- 
sions. Part I. pp. 509. Philadelphia, Carey, Lea & Blanchard, 1835 



468 



QUARTERLY PERISCOPE. 

FOREIGN INTELLIGENCE. 

AlfATOMT. 



Pa«e. 

1. Observations on the Structure 
of the Brain. By Professor Eh- 
renberg - - . _ 471 

2. Abstract of Observations on the 
Structure and Functions of the 



Paok. 
Nervous System. By James Ma- 
cartney, M. D. - - - 473 
Connexion Between the Uterus 
and the Placenta Examined. By 
Daniel Noble, Esq. - - 476 



Physiology, 



Abstract of Observations on the 
Motions and Sounds of the Heart. 
By Hugh Carlile - - 477 



5. Case of Superfoetation 



481 



Pathology. 



6. On the Pathology of Jaundice. 

By Wilham Stokes, M. D. 8tc. 481 

7. On the Cause of the Yellow 
Vision in Jaundice. By William < 
Stokes, M. D. - - - 484 

8. On Icterus Infantum. By Wil- 
liam Stokes, M. D. - - 486 

9. Jaundice from Gastro-duode- 
nitis. By William Stokes, M. D. 487 

10. OnaformofGastro-duodenitis 
resembling Yellow Fever. By 
William Stokes, M. D. &c. 490 

11. Jaundice from Obstruction of 
the Biliary Ducts by Calculi. By 
William Stokes, M. D. - 492 



12. Spasmodic Jaundice. By Wil- 
liam Stokes, M. D. - - 494 

13. On the Discharge of Fatty 
Matters from the Bowels. By 
William Stokes, M. D. - 495 

14. Microscopical Experiments on 
Inflammation. By Dr. C. F. 
Koch ... - 498 

15. Hepatitis. By William Stokes, 

M. D. . - - - ib, 

16. Hepatic Abscess. By William 
Stokes, M. D. - - . SOS 

17. Termination of Hepatic In- 
flammation in Gangrene. By 
William Stokes, M. D. - 505 



286 



CONTENTS. 



18. Distended Gall-Bladder. 
William Stokes, M. D. 

19. Chronic Hepatitis. By Wil- 
liam Stokes, M. D. - 

20. Results of a Series of Experi- 
ments in Revaccination, per- 



Page. 

By 



506 



507 



Page. 

formed in the Royal Army of 
Wirtemberg". By Dr. Heim 508 
21. Discovery of an Insect in Itch, 
by Experiments lately made at 
the Hopital St. Louis, Paris. 
By M. Renucci - - - 510 



Practice of Medicike. 



22. On the Treatment of Dysen- 
tery. By William stokes, M. D. 514 

23. On Mercurial Action. By Wil- 
liam Stokes, M. D. - - 517 

24. On Tympanitis. By William 
Stokes, M. D. - - - 518 

25. Treatment of Biliary Calculi. 

By William Stokes, M. D. - 519 

26. Treatment of Acute Hepatitis. 

By William Stokes, M. D. - 520 

27. Treatment of Chronic Hepa- 
titis. By William Stokes, M. D. 525 

28. On the Use of Colchicum Au- 
tumnale in Leucorrhoea By 
George Ritton, Esq. - - 527 

29. Treatment of sore Nipples by 
Nitrate of Silver. By Dr. A. J. 
Hanney , . - _ ib. 



30. Herpes Preputialis. By M. 
Biett - - - - - 527 

31. On some of the Effects of the 
Secale Cornutum. By Dr. Mul- 

ler ----- ib, 

32. Sulphuric Acid as a Prophy- 
lactic against Saturnine Colic. 

By M. Gendrin - - - 528 

33. Chlorine Inhal'ations in Chro- 
nic Pulmonary Catarrh. By Dr. 
Toulmouche - - - ib. 

34. On the Employment of the 
Alcoholic Extract of Aconite in 
the Treatment of Acute Arti- 
cular Rheumatism. By Dr. 
Lombard - - - - ib. 



Ophthalmology. 



35. Observations on the Use of 
Corrosive Sublimate in Ophthal- 
mia. By M. F. Dupouget 529 



36. Treatment of Fistula Lach- 
rymalis by the Perforation of the 
Maxillary Sinus. By M. Laugier 529 



Stjrgert. 



37. Tumours over the Body. By 
Mr. Brodie - - * - 529 

38. Urinary Syphon. By Mr. Law- 
yer 530 

39. Amputation of the Neck of 
the Uterus. By M. Lisfranc ib. 

40. Application of the Dynamo- 
meter. and Pulley to the Treat- 
ment of Luxation. By Dr. Se- 
dillot - - . - ib. 

41. Case of Lithotomy and Litho- 
tripsy in the same Individual. 

By Dr. Phillips - - - 531 

42. Imperforate Anus — New Ope- 
ration for its Cure. By M. Roux ib. 

43. Amputation of the Thigh for 
Fungous Hsematodes in a New- 
Born Child. By Dr. Paul - 53^ 

44. Polypi cured by a Solution of 



Sulphate of Zinc. By Mr. Jo- 
seph Dallaway - - - 532 

45. Wound of the Heart — Patient 
survived Ten days. By Dr. 
Fris ib. 

46. Sudden Death from the En- 
trance of Air into the internal 
Jugular Vein. By Dr. Ulrick 533 

47. Strangulated Hernia relieved 
by extract of Belladonna. By 
Dr. Frankel . - - ib. 

48. Case of Uniiniled Fracture of 
the Femur cured by the intro- 
duction of a Seton. By E. 
M'Dovvell, Esq. - - ib. 

49. Lithotripsy. By Mr. Lloyd 534 

50. Relinion of Fracture of the 
Cervix Femoris within the Cap- 
sule. By Thomas Faw^ington ib. 



CONTENTS, 



287 



Midwifery. 



Page. 
51. Case of Deformed Pelvis, in 
which labour was brought to a 
successful termination by Sym- 



Page. 
physeotomy. By Professor Pe- 

truni 535 

52. Premature Delivery. By Dr. 
Schippan - » - - 536 



Mebicai/ Jurisprudence. 



53. Fissures in the Cranial Bones 
of Infants, after a Natural Deli- 
very. By Professor Siebokl 537 

54. Hydro-oxide of Iron an Anti- 



By Drs. 



dote to Arsenic Acid. 
Bunsen and Berthold - - 537 
55. Case of Poisoning" by Carbo- 
nate of Barytes. By Dr. Wilson 539 



Chemistry. 



56. On Creosote. By M. Reichen- 
bach ----- 539 

57. New Method of Preparing 
Creosote. By M. Calderini 541 



58. Analysis of four Pulmonary 
Calculi. By Professor Sgarzi 542 



Miscellaneous. 



59. Preservation of Leeches. By 
M.Bertrand - - - 542 

60. Sphygmometer, an Instru- 
ment which makes the Action 



of the Arteries apparent to the 
Eye. By Jules Herisson, M. D. 543 

61. Miasmata. By M. Boussin- 
gault 544 

62. Baron Dupuytren - - ib. 



AMERICAN INTELLIGENCE. 



Note on the Anatomical Charac- 
ters of Cholera. By W. E. Ilor- 
ner, M. D. Professor of Ana- 
tomy in the University of Penn- 
sylvania - - . - 545 

Case of severe Injury of the Head 
terminating Favourably. (Re- 
ported by Caspar Morris, M. D.) ih. 

Case of Lepra Vulgaris, cured by 
rigid Abstinence. By Aristide 
llodrigue, M. D. - - 547 

Case of Malignant Cholera, in 
which Delivery at Term took 
place, during its Advanced or 
Collapsed Stage, and the patient 
recovered. By F. West, M. D. 548 

On the Tapioca. By Henry Per- 
rine, M. 1). Consul of the United 
Slates at Campeachy. (Extract 
from a Letter to the Editor) 549 



Climate of the Havana. By H. Per- 
rine, M. D. - - - 550 

Case of Partial Amnesia, in which 
the Memory for Proper names 
was I>ost. By Daniel Drake, 
M. D. - - . - 551 

On the Employment of Nux Vo- 
mica and its Preparations in 
Dysentery . - - 552 

Singular condition of the Knee 
Joint in a New-born Infant. By 
Dr. D. H. Bard, of Troy, Ver- 
mont _ - - - 555 

Urea, Benzoic Acid, and Xanthic 
Oxide, in Diabetic Urine. By 
Charles T. Jackson, M. D. ib. 

Intussusception with Stercorace- 
ous Vomiting, successfully treat- 
ed by Inflation. By J. Wood, 
M. D. . - - . 556 



288 



CONTENTS. 



Page. 
On the Plant which furnishes the 

Jalap. By R. E. Griffitii, M. D. 558 
Dartmouth College - - 559 

Medical Institution of Geneva Col- 
lege, New York - - ih. 
Berkshire Medical Institution 560 
Transylvania University - ib. 



Pagk. 

Sphygmometer. By Dr. J. G. Nan- 
crede - - _ . 560 

Sarlandiere's Anatomy - ib. 

Professor Caldwell's Thoughts on 
Physical Education - - ib. 

Marshall Hall's Principles of Diag- 
nosis - . _ - ib. 

Ijtdex - - . - . 561 



t 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES 



No. XXXI.— May, 1835. 1 



COLLABORATORS. 



Jacob Bigelow, M. D. Professor of 
Materia Medica in Harvard Univer- 
sity ^ Boston. 
Edward H. Bartok, M. D. of New 

Orleans. 
Hexrt Bronsoit, M. D. of Albany^ New 

York. 
REYjfEi. CoATEs, M. D. of Philadelphia. 
Walter Chaining, M. D. Professor of 
Midwifery and Legal Medicine in 
Harvard University ^ Boston. 
N. Chapman, M. D. Professor of the 
Institutes and Practice of Physic and 
Clinical Practice in the University of 
Pennsylvania. 
John Redman Coxe, M. D. Late Profes- 
sor of Materia Medica and Pharmacy 
in the University of Pennsylvania. 
D. Francis Condie, M. D. of Phila- 
delphia. 
William C Daniell, M. D. of Savan- 

nahy Georgia. 
William P. Dewees, M. D. Profes- 
sor of Midwifery in the University of 
Pennsylvania. 
S. Henry Dickson, M. D. Professorof 
the Institutes and Practice of Medicine 
in the Medical College of the state of 
South Carolina. 
Benjamin W. Dudley, M. D. Profes- 
sor of .Anatomy and Surgery in Tran- 
sylvania University. 
"Robley DtJNGLisoN, M. D. Professorof 
Materia Medica, Therapeutics, Hy- 
giene, and Medical Jurisprudence, in 
the University of Maryland. 
GouvERNETjR Emerson, M. D. of Phila- 
delphia. 
Paitl F. Eve, M. D. Professor of Sur- 
gery in the Georgia Medical College. 
John W. Fuincis, M. D. Late Profes- 
sor of Obstetrics and Forensic Medi- 
cine in Rutgers Medical College, New 
York. 
W. W. Gerhard, M. D. of Philadelphia. 
William Gibson, M. D. Professor of 
Surgery in the University of Pennsyl- 
vania. 
R. E. GniTvnH^M.'D. of Philadelphia. 
E. Hale, M. D. of Boston. 
George Hay ward, M. D. Professor of 
the Principles of Surgery and Clini- 



cal Surgery in Harvard University^ 
Boston. 

William E. Horner, M. D. Professor 
of Anatomy in the University of 
Pennsylvania. 

David Hosack, M. D. Late Professor 
of the Institutes and Practice ofMedi' 
cine in Rutgers Medical College, New 
York. 

Ansel W. Ives, M. D. of New York. 

Samuel Jackson, M. D. Assistant to the 
Professor of the Institut es and Practice 
of Medicine and Clinical Practice in 
the University of Pennsylvania. 

Samuel Jackson, M. D. of Northum- 
berland, Pennsylvania. 

John George Morgan, M. D. Pro- 
fessor of the Principles and Practice 
of Surgery in Geneva College, New 
York. 

Valentine Mott, M. D. Professor of 
Pathological and Operative Surgery 
in the College of Physicians and Sur- 
geons, New York. 

James Moultrie, Jr. M. D. Professor 
of Physiology in the Medical College 
of the state of South Carolina. 

Reuben D. Mussey, M. D. Professor 
of Anatomy and Surgery in Dart- 
mouth College, New Hampshire. 

T. D. Mutter, M. D. of Philadelphia. 

R. M. Patterson, M. D. Professor of 
Natural Philosophy in the University 
of Virginia. 

Philip Syng Phystck, M. D. Profes- 
sor of Anatomy in the University of 
Pennsylvania. 

Thomas Sewall, M. D. Professor of 
Anatomy and Physiology in the Co- 
lumbian College, District of Columbia. 

Ash BEL Smith, M. D. of Salisbury, 
North Carolina. 

A. F. Vache, M. D. of New York. 

John Ware, M. D. Assistant Professor 
of the Theory and Practice of Physic 
in Harvard University, Boston. 

John C. Warren, M. D. Professor of 
Anatomy and Surgery in Harvard 
University, Boston. 
Thomas H. Wright, M. D. Physician 

I to the Baltimore Aims-House Injir- 

I mary. 



EDITOR— Isaac Hays, M. D. 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



VOL. XVI. 



PHILADELPHIA: 
CAREY, LEA & BLANCHARD. 

1835. 



TO READERS AND CORRESPONDENTS. 



Communications have been received from Drs. Horner, Porter, Osgood, 
W. G. Smith, Gragin, Hallowell, Mettauner, Southworth, Weems, 
Roberts, and Webber. 

The following- works have been received: — 

A System of Dental Surgery. In three parts. 1st. Dental Surgery as a 
Science. 2d. Operative Dental Surgery. Sd. Pharmacy connected with 
Dental Surgery. By Samuel Sheldok Fitch, M. D. Surgeon Dentist. Second 
edition. Philadelphia, 1835, Carey, Lea & Blanchard. (From the publishers.) 

Illustrations of Surgical Anatomy, with explanatory references; founded on the 
work of M. Blandin. By John G. M. Burt, Surgeon Extraordinary to the King 
in Scotland. Second edition. Glasgow. (From the author.) 

A Synopsis of the Flora of the Western States. By John L. Ridpell, A. M. 
Lecturer on Chemistry; Member of the Historical and Philosophical Society, 
of Ohio, &,c. &,c. Cincinnati, 1835. pp.116. 8vo. (From the author.) 

Chemical and Medical Researches on Kreosote, its Preparation, Properties, 
and Use. By E. Miguet, M. D. Sec. Translated from the French. By William: 
Wetherill, M. D. Philadelphia, 1835. (From the translator.) 

Catalogue of the Trustees, Faculty, and Students of the Medical Department 
of the University of Maryland. Baltimore, 1835. (From Professor Dunglison.) 

Dissection of the Eye of the Streaked Bass, Perca nobilis vel Mitchelli, with 
Observations on the Accommodation of the Eye to Distances. By W. C. Wal- 
lace, M. D. Surgeon to the New York Institution for the Blind. (From the author.) 

A Catechism of Medical Jurisprudence; being principally a Compendium of 
the Opinions of the best Writers upon the subject. With a Preliminary Dis- 
course upon the importance of the Study of Forensic Medicine. Designed for 
Physicians, Attornies, Coroners, and Jurymen. By Stephen W. Williams, M. D. 
Late Professor of Medical Jurisprudence in the Berkshire Medical Institution, 
&c. Northampton, 1835. (From the author.) 

Introductory Lecture on the Climate and Salubrity of New Orleans; and its 
Suitability for a Medical School. By Edward H. Barton, M. D. Professor of 
Materia Medica, Therapeutics, and Hygiene. Published at the request of the 
Faculty. New Orleans, 1835. (From the author.) 

Journal of the Proceedings of a Convention of Physicians of Ohio, held in the 
City of Columbus, on the 5th of January, 1835. Cincinnati, 1835. (From Dr. 
William M. Awl, Corresponding Secretary.) 

A Catechism of Phrenology, illustrative of the Principles of that Science. 
By a Member of the Phrenological Society of Edinburgh. From the sixth Glasgow 
edition. Philadelphia, Carey, Lea & Blanchard, 1835. (From the pubhsliers.) 

Introductory Address delivered at the opening of the Medical College of the 
State of South Carohna, November 10th, 1834. By James Moultrik, M. D. 
PubUshed at the request of the Class. Charleston, 1834. (From Professor Frost.) 
Introductory Address on the EstabHshment of the Medical College of 
Louisiana. By Thomas Hunt, M. D. Professor of Anatomy and Dean of the 
Faculty. New Orleans, 1835. (From the author.) 

Report on the New Map of Maryland, and of the Geologist appointed to make 
a Geological Survey of the State. (From Professor Ducatel.) 

An Address delivered before the Young Men's Temperance Society in 

1* 



b TO READERS AND CORRESPONDENTS. 

Lowell, March 8th, 1835. By Elisha Babtlett, M. D. Published by the 
Society. (From the author.) 

Archives Generales de Medecine, February, March, April, May, June, July, 
August, September, October, November, 1834. (In exchange.) 

Revue Medicale Francaise et etrangere, August, September, October, No- 
vember, December, 1834. (In exchange.) 

Journal Hebdomadaire des Progres des Sciences et Institutions Medicales, 
August, September, October, November, December, 1834. (In exchange.) 

Journal de Pharmacia et des Sciences Accessoires, September, October, 
November, December, 1834. (In exchange.) 

Annales de la Medecine Physiologique, July, August, September, October, 
November, 1834. (In exchange.) 

Gazette Medicale, August, September, October, November, December, 
1^34. (In exchange.) 

La Lancette Frangaise; Gazette des Hopitaux, August, September, October, 
November, December, 1834. (In exchange.) 

Memorial Encyclopedique et Progressif des Connaissances Humaines, 
August, September, October, November, and December, 1834. (In exchange.) 

Edinburgh Medical and Surgical Journal, for January, 1835. (In exchange.) 

Medico-Chirurgical Review, January, 1835. (In exchange.) 

London Medical Gazette, December, 1834, January, 1835. (In exchange.) 

Wissenschaftliche Annalen der Gesammten Heilkunde. Herausgegeben von 
Dr. J. F. C. Hecker, Professor der Heilkunde an der Friederich-Wilhelms- 
Universitat zu Berhn, March, April, May, June, July, August, September, 
October, November December, 1833, January, February, March, April, May, 
1834. (In exchange.) 

Ephemeriden der Naturkundige Wetenschappen, for July, August, Septem- 
ber, October, 1834. (In exchange.) 

The Transylvania Journal of Medicine and the Associate Sciences, December, 
1834. (In exchange.) 

North American Archives of Medical and Surgical Science, February, March, 
April, 1835. (In exchange.) 

The Medical Magazine, Februar}-, March, April, 1835. (In exchange.) 

Western Medical Gazette, January, February, 1835. (In exchange.) 

Boston Medical and Surgical Journal, Vol. XII, No. 1 to 11. (In exchange.) 

Authors of new medical books, desirous of having them reviewed or noticed 
in this Journal at the earliest opportunity, are invited to transmit to the Editor 
a copy as soon after publication as convenient, when they will receive prompt 
attention. Under ordinary circumstances, very considerable delay is caused by 
the circuitous routes through which they are received. 

Papers intended for publication, should be sent,/ree of expense^ as early after 
the appearance of the Journal as possible, in order to be in time for the ensuing 
number. Such communications should be addressed to " Caret, Lea & Blait- 
CHARD, Philadelphia, for the Editor of the American Journal of the Medical 
Sciences." 

All letters on the business of the Journal to be addressed exclusively to the 
publishers. 



CONTENTS 



ORIGINAL COMMUNICATIONS. 

ESSAYS. 
Aut. Pagi. 

I. Reports of Cases Treated in the Surgical Ward of the Pennsylvania 
Hospital. By T. S. Kirkbride, M. D. Resident Physician - - 13 

II. Reports of Cases Treated in the Medical Wards of the Pennsylvania 
Hospital. By W. W. Gerhard, M. D. Resident Physician. (Part 2d, In- 
termittent Fever — Chronic Dysentery) 35 

III. On the Anatomical Characters of Asiatic Cholera, with Remarks on 
the Structure of the Mucous Coat of the Alimentary Canal. By W. E. 
Horner, M. D. Professor of Anatomy in the Universily of Pennsylvania 58 

IV. Case of Inverted Uterus. By Burleigh Smart, M. D. of Kennebeck, 
Maine. (See also p. 250) 81 

V. Remarkable Case of Ascites in a Child. By John A. Elkinton, M, D. 
[With a wood-cut] 84 

VI. Case of Monstrosity, with some Remarks upon Moles, Marks, &c. By 
Stephen W. Williams, M. D. Late Professor of Medical Jurisprudence 

in the Berkshire Medical Institution. [With a wood-cut] - - 88 

VII. A Case of Fractured Spine, with Depression of the Spinous Process, 
and the Operation for its Removal. By David L. Rogers, M. D. of New 
York city. (Communicated by S. R. Kirby, M. D.) - - - 91 

VIII. Cases of Pericarditis and Hydrops Pericardii. By C. W. Pennock, 

M. D. 94 

IX. Case of Phlebitis. By John Andrews, M. D. of Steubenville, Ohio 106 

MEDICAL EDUCATION AND INSTITUTIONS. 

X. System of Medical Education, and Arrangement of the Medical Profes- 
sion in the Austrian States 110 

REVIEW. 

XI. An Inquiry into the Principles and Practice of Medicine, founded on 
original Physiological Investigations. By G. Calvert Holland, M. D. 
Physician to the Sheffield General Infirmary. — Quandd tales amentia et 
abusus cessaturus est f et quandd aurea mediocritus et sobrietas in terri- 
torio medicorum triumphatura? — Schmidtmann. Sum. Obs. Med. Lon- 
don, 1834. Vol. L 8vo. pp. 540 118 

BIBLIOGRAPHICAL NOTICES. 

XII. Des H^morroides et de la Chute du Rectum. Par Aim. Lepelletier, 
de la Sarthe, Professeur de Physiojiogie et de Pathologiej Membre de 



8 CONTENTS. 

Art. Page. 

PAcademie lloyale de Medeclne, ExChirurgien en Chef h, THopital du 
Mans. Paris, 1834. pp. 168. 8vo. 145 

XIII. A Treatise on the Urethra; its Diseases, especially Stricture and their 
Cure. By Benjamin Phillips, Author of a Series of Experiments made 
to demonstrate that Arteries may be obliterated without Ligature, Com- 
pression, or the Knife. London, 1832. pp. 317. 8vo. - - . 150 

XIV. Observations on the Original Causes of Malignant Cholera. By John S. 
Bowron, M. D. New York. C. S. Francis, 1835, p. 41. - - - 155 

XV. A Catechism of Medical Jurisprudence; being principally a Compen- 
dium of the opinions of the best Writers upon the subject. With a 
Preliminary Discourse upon the Importance of the Study of Forensic Me- 
dicine. Designed for Physicians, Coroners and Jurymen. By Stephen 
W. Williams, M. D. Late Professor of Medical Jurisprudence in the Berk- 
shire Medical Institution; Fellow of the Massachusetts Medical Society, 

&c. Northampton, 1835. pp. 205. 12mo. 159 

XVI. The American Cyclopedia of Practical Medicine and Surgery; a Digest 

of Medical Literature. Edited by Isaac Hays, M. D. &c. &c. - 162 

XVII. Des Diverses Methodes et des differens Procedes from I'obliteration 
des Arteres, dans le Traitement des Anevrismes; de leurs Avantages et de 
leurs Inconveniens respectresses. Par J. Lisfranc, vice-President de 
I'Academie Royale de Medecine, Chirurgien en chef de La Pitie, &c. 
Paris, 1834. pp. 152 167 

XVIII. Transactions of the Medical and Physical Society of Calcutta. Vol. 

VI. Calcutta, 1833, 8vo. pp. 509 - ..... 168 

XIX. The Principles of Diagnosis. By Marshall Hall, M. D., F. R. S. 
London Edition, etc. Second edition, entirely re-written. New York, 
1835, 8vo. pp. 463 170 

XX. Dissertatio Inauguralis de Dentitione Infantali, cum Adjuncta Disqui- 
sitione de Spasmiset Antispasmodicis, quam pro Summis in Arte Medica 
Honoribus rite Obtinendis Publice Defendere Studebit. Auctor Fre- 
dericus Adolphus Uldal!, Medicinae Licentiatus, Chirurgiae Candidatus. 
Haunis, MDCCCXXXHI. 8vo. pp. 93 

An Inaugural Dissertation on Infantile Dentition, to which is annexed a 
Disquisition on Spasm and Antispasmodics. By F. A. Uldall. Copen- 
hagen, November, 1833 172 

XXI. Dissertatio de EfFectibus Jodii in Organismum Humanum Usuque 
ejus Medico, quam Scripsit et pro Licentia Summos in Arte Medica 
honores postea capessendi publico Eruditorum examini modeste sub- 
mittit. Fredericus Adolphus Uldall, Chirurgiac et Medicinse candidatus. 

Haunise, MUCCCXXXIIL 8vo. pp. 78 
A dissertation on the Effects of Iodine upon the Human Organism, and its 
Use as a Medicine. By F. A. Uldall, Copenhagen, February, 1833 173 

XXII. Sur les Vaisseaux Absorbans du Placenta et du Cordon Ombilical. 
Par V. Fohmann, Professeur a I'Universite de Liege. ( Avec une Planche 
Coloriee.) Liege, 1832 174 

XXUI. Illustrations of Surgical Anatomy^, with explanatory References; 



CONTENTS. 



9 



Art. Pagi. 

founded on the work of M. Blandin. By John G. M. Burt, Surgeon ex- 
traordinary to the King in Scotland. Second edition. Glasgow - 176 

XXIV. Considerations sur la Nature et le Traitment du Cholera-morbus, 
Suivies d'une Instruction sur les Prec^ptes Hygieniques centre cette 
Maladie. Par le Chevalier J. R. L. De Kerckhove dit de Kirckhoff, 
D. M. Ancien Medecin en Chef des Hopitaux Militaires; Vice-president 
Honoraire de la Societe Grand-Ducale de Mineralogie d'lena; Comman- 
deur et Chevalier de Plusieurs Ordres; Membre de la Plupart des Aca- 
demies et des Societes Savantes de I'Europe; Membre Honoraire des 
Academies Americaines des Beaux-arts et des Societes de Medecine de 
New-Yorck et de Philadelphie; Associe-correspondant de I'Institut 
d' Albany 5 du Lycee d'Histoire Naturelle de New-Yorck; de 1' Academic 
des Sciences et Arts de Batavia, &c. ; Membre de la Commission M^dicale 
de la Province d'Anvers. pp. 217. 8vo. --.-.. 177 



QUARTERLY PERISCOPE. 

POREIGN INTELUGENCE. 



ASATOMT. 



Page. 
1. Lymphatic System in Reptiles. 
By Professor Muller - - 178 



Page. 

2. New Membrane in the Human 
Eye. By Dr. G. P. Poggi - 179 



Pathology. 



179 



181 



3. Case of Disease of the Heart. 
By Dr. Hanna 

4. Obliteration of the Vena Cava 
Superior, as it enters the Auricle. 
By Dr. Reid 

5. Purulent Decomposition of the 
Blood. By M. Duplay - tb. 

6. Inflammation of the Membranes 

of the Ovum. By Dr. Ollivier ib. 

7. Hypertrophy of the Muscular 
Coat of the Stomach. By Dr. Otto 182 

8. Anatomi co-Pathological Resear- 
ches on the Pneumogastric 
Nerve. By J. T. H. Albers, of 
Bonn. With Observations on Dis- 
eases of that Nerve. By Dr. 
Hankel 

9. Itch. By M. J. D. Renucei 

10. Case of Apoplexy in conse- 
quence of Effusion of B lood from 
Aneurism and Rupture of the 
middle Meningeal Artery. By 
Dr. John Gairdner 

11. Loss of Cerebral Substance in 



ib. 
183 



184 



an old Apoplectic Case. By Dr. 
Abercrombie . - - 184 

12. Tumour of the Cerebellum, 
with remarkable Course of the 
Symptoms. By Dr. Abercrombie 185 

13. Case illustrating the Anoma- 
lous Nervous Symptoms occa- 
sionally induced by Taenia. By 
John Scott, M. D. 

14. Case of Apoplexy. By Dr. A. 
D. Maclagan ... 

15. Existence of Charcoal in the 
Lungs. By Dr. G. Pearson 

16. Occlusion of the Ductus Com- 
munis Cholidochus. By J. 
M'Clelland, Esq. 

17. Rupture of the Heart. By Mr. 
Gait 

18. Case of Hepatic Abscess. By 
William Stokes, M. D. 

19. Case of Aneurism of the He- 
patic Artery — Distention of the 
Liver with Bile. By William 
Stokes, M. D, - 



186 



187 



ib. 



188 



189 



ib. 



191 



10 



CONTENTS. 



20. Inflammation and Abscess 
the Abdominal Parietes over the 
Hepatic Region. By William 
Stokes, M. D. - 

21. Complicationof Hepatitis with 
Disease of the Heart. By Wil- 
liam Stokes, M. D. - 

22. Embryonary state of the Liver 
mistaken for Chronic Hepatitis. 
By William Stokes, M. D. - 

23. On the Connexion of Hepatic 
with Gastro-intestinal Disease — 
Modes of Transmission of Dis- 
ease from the Mucous Surface 
to the Liver. By William Stokes, 
M. D. .... 

24. On Phlebitis of the Vena 
Porta. By William Stokes, M. D. 



Page. 
of 



192 



193 



194 



196 



Pa6K. 

25. Singular Case of Pulmonary, 
Hepatic, and Intestinal Fistula. 

By William Stokes, M. D. - 197 

26. On the Organization and Origin 
of Intestinal Worms. By William 
Stokes, M. D. - - - 198 

27. Pathology of Intestinal Worms. 

By William Stokes, M. D. - 201 

28. On the supposed Power of 
Worms of Perforating the Intes- 
tines. By William Stokes, M. D. 202 

29. Worms which inhabit the In- 
testinal Canal in Man. By Wil- 
liam Stokes, M. D. - - 203 

30. Symptoms of Intestinal Worms. 

By William Stokes, M. D. - ^ 204 

31. Causes of Worms. By Wil- 
liam Stokes, M. D. - - 206 



32. Diagnosis of Inflammation of 
the Spinal Dura Mater. By Pro- 
fessor Albers . - - 207 



Diagnosis. 

33. Frottement observed in Peri- 
tonitis. By Professor Beatty 



209 



Etiologt. 

34. Ofthe Influence of Professions 
upon Phthisis Pulmonalis. By M. 
Lombard - - - - 210 

35. Case in which Urgent Symp- 



toms of Asthma appeared to be 
Induced by Electricity, excited 
by New Feathers. By John Ross 212 



Pbactice of Medicine. 
36. On the Vis Medicatrix Naturse. 



By Professor Tommasini 

37. Use of Chloruret of Lime in 
Blenorrhagia. By Professor 
Graefe .... 

38. Hypertrophy of the Mammse 

39. Hemicrania cured by Acetate 



213 



214 
215 



of Morphine applied endermi- 
cally. By Dr. Magister 

40. Observations upon the Thera- 
peutic Effects of Creosote. By 
Dr. Reich 

41. Treatment of Worms. By 
WilUam Stokes, M. D. 



216 



ib. 
217 



SUHGERT. 



42. Pathological Appearances of 
Seven Cases of Injury of the 
Shoulder- Joints, with Remarks. 

By John G. Smith, Esq. - 219 

43. Prolapsusof the Rectum cured 
by the Application of the Actual 
Cautery. By Professor Kluys- 
kens - - - - 224 

44. Varicose Tumour on the Scalp 
of a New-Born Infant. By Pro- 
fessor Mersseman - - ib. 

45. Complete Luxation of the 
Knee. By Dr. Gorde - 225 

46. Case of unusual Dislocation of 
the Hip-joint. By Robert Keate ib. 



By 



47. Excessive Prolapsus Ani. 
Dr. Taylor - 

48. Displacement of one of the 
Semilunar Cartilages of the 
Knee-joint. By Dr. Reid - 

49. Case of Spontaneous Luxation 
ofthe Vertebra Dentata. By Dr. 
William Thomson 

50. Mastic for filUng Carious Teeth 228 

51. Spontaneous Dry Gangrene 
Cured by Bleeding - - ih. 

52. Case of Incised Wound of the 
Throat. By Dr. A. Gilmore 229 



226 



ib. 



227 



CONTENTS. 



11 



Midwifeht. 



Page. 

53. Aqueous Discharge after Par- 
turition. By Samuel Ashwell, 

M. D. .... 229 

54. On the Absorbent Power of 
the Uterus. By Professor Naegele 232 

55. On the Loss of Blood during 
Labour, in consequence of the 
Rupture of a Varix - - 233 

56. Twisting- of the Umbilical Cord 
around the Body and Limbs of 
the Foetus. By Dr. Siebold 234 



Pass. 

57. Case of Abortion, with Reten- 
tion of the Placenta; a second 
Pregnancy, with Abortion again, 
and the Discharge of the Ovum 
and Placenta of the preceding 
Pectus. By Dr. Pirondi - 235 

58. A Cancerous Ulcer at the Neck 
of the Uterus, cured by Cooling 
Injections. By Dr. F. Alliot 236 



Medical Jurisprudence. 



59. On the Death of New-born 
Infants depending on anormal 
States of the Umbilical Cord. 

By Dr. Kohlschwetter - 237 

60. Hydrate of the Tritoxide of 



Iron as an Antidote to Arsenic 
Acid - - - - - 239 
61. Detection of Arsenic when 
mixed with Organic Substances. 
By M. Taufflier - - - 240 



Medical Statistics. 



62. On the Probable Duration of 
Life Among Medical Practi- 
tioners. By Professor Casper 241 



63. Austrian Statistics 



244 



Miscellaneous. 

64. Abolishment of sanatory cor- i 65. Method of Teaching Anatomy 245 

dons in Spain - - - 245 j 



AMERICAN INTELLIGENCE. 



Caesarean Operation. By Professor 
Gibson .... 

Case of Enlargement and Hyper- 
trophy of the Ileum. By Mason 
L. Weems, M. D. 

Case of Discharge of Blood from 
the Bowels of aNew-born Infant. 
By C. R. Gilman, M. D. - 

Case of Monstrosity. By Aristide 
Roderique, M. D. 

Anatomical Structure of a Bifurcat- 
ed Umbilical Cord in a Case of 
Twins. By William S. Reynolds, 
M. D 

Case of Retention of Urine Cured 
by a Solution of Muriate of Am- 
monia. By Alexander Somer- 
vail, M. D. 

Dr. Smart's 
Uterus 

Accumulation 



Case of Inverted 



of 



the Cranium and Scalp 
Robert Lebby, M. D. - 



Fluid between 
By 



246 



ib. 



248 



249 



ib. 



250 
ib. 



ib. 



Treatment of Burns with Yellow 
Wash, (AquaPhagoedenica.) By 
Dr. Hintze - - - - 251 

Apoplexy from excessive Reple- 
tion of the Stomach — Sudden 
Death — Large Extravasation in 
the Vicinity of the Fissure of 
Sylvius. By Professor Geddings 252 

Dissection of a Uterus at the Sixth 
Month of Inpregnation. By J. 
B. S. Jackson ... ib, 

Hon. George W. Erving and 
Swaim's Panacea - - 255 

Case of Poisoning by Oil of Tansy. 
By Charles T. Hildreth, M. D. 256 

Dr. North's Inquiries on Diet 259 

University of Pennsylvania - 260 

University of Maryland - ib. 

Transylvania University - ib. 

Medical College of the State of 
South Carolina - - - ib. 

Advertisements - - 261 



<i =^ 




THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES, 



Art. T. Obscure Pericarditis — Dilatation of the Heart — Peculiar 
Species of Tumour in the Right and Left Ventricles, and Bight 
Auricle — (Edema of the Fauces and Larynx, and Glottis — Death 
from Suffocation, By Samuel Jackson, M. D. Assistant to the 
Professor of the Institutes and Practice of Medicine and Clinical 
Practice in the University of Pennsylvania. [With a coloured 
Plate and two wood-cuts.] 

JMR. , aged fifty-four years, temperament sanguine nervous; 

previous health generally good; had suffered in former years attacks 
of acute inflammation of abdominal viscera; had been actively en- 
gaged in business for many years, and exposed to great mental 
anxiety; habituated to the moderate but daily use of spirituous drinks. 
In the commencement of January, 1834, he returned from a fatiguing 
journey of twelve hundred miles, during which he was exposed to 
severe cold, especially in crossing the Alleghany ridge. From the 
state of the roads, the stages could not run, and anxious to reach 
home, he travelled across the mountains in an open mail cart. He 
suffered severely from the cold and violent jolting, the vehicle being 
without springs. 

After reaching home, he complained of excessive fatigue, kept in 
bed for two days, took some medicine without advice, and resumed 
his accustomed pursuits. He kept about, complaining frequently of 
shortness of breath when ascending stairs, of being easily fatigued, 
and often sighed deeply. This last circumstance was attributed to 
mental causes, at the time, as his affairs were not in a very satisfac- 
tory state. On the 29th of January, I was requested to see him. 

No. XXX.— February, 1835. 25 



290 Jackson's Case of Disease of the Heart and Larynx. 

The night previous he had been out on a visit, complained of being 
cold and fatigued when vv^alking home, and in the morning felt too 
unwell to get up. I found him complaining of cough, with sense of 
oppression in the chest; he had no heat of skin; the face peculiarly 
pallid; pulse exceedingly feeble and frequent; the chest every where 
resonant on percussion; the respiratory murmur pure in every part of 
the chest, gave no indication of pulmonary affection; the action of 
the heart rapid, its sound feeble. A blister was directed to the 
chest, with a composing cough mixture. 

The next day, 30th, he felt relieved; the oppression diminished. 

February 1st. — Had passed a restless night; indescribable feelings 
in the chest; skin cool and shrivelled. Directed emulsion of assafoe- 
tida, with acetat. opii. 

2rf. Night again restless; skin cold, pallid, face waxy aspect; great 
anxiety; the chest again examined, furnished same pulmonary indi- 
cations; the heart alone seemed affected; the pulse irregular, so rapid 
as scarcely to be counted; the sound of the heart feeble and indis- 
tinct; the organ appeared to labour; no morbid sounds; head re- 
markably clear; stomach in excellent state. In crossing the moun- 
tains he had used stimulants more freely than usual, and suspected 
his present exhaustion might proceed from their sudden withdrawal. 
The suggestion was adopted, and warm toddy, with carb. ammonias 
prescribed. 12 M. Same state. 3 P. M. Has rallied in some mea- 
sure; skin warmer, and feels more comfortable. 8 P. M. Skin still 
warmer, dry; pulse has more force. Continue stimulants. 

Sd. Night more tranquil than preceding; had one sinking spell, 
almost approaching to fainting; examination of the chest presented 
some indications as before, both as to the lungs and the heart; has 
a sense of extreme prostration and debility. When lying with his 
head low, the face is purple, from the stagnation of the venous circu- 
lation; when it is elevated, it immediately becomes pallid. The 
veins of the extremities very much distended, and cannot be emptied 
by pressing upwards along their course. Senses and intelligence 
are perfect; stomach in excellent condition; bears the stimulants 
administered every half hour perfectly well; sinapism applied along 
the spine; blister over the region of the heart, and on the lower ex- 
tremities; calomel gr. i. every hour. No change occurred during 
the day. When the stimulants are withheld, the sense of sinking 
and disposition to fainting comes on. The stimulants were adminis- 
tered every half hour. No other effect apparent than to obviate the 
tendency to fainting and sinking. At 10 P. M. Tinct. opii, gtt. xxv. 

4th, In the night had one sinking spell: this morning pulse rapid, 



Jackson's Case of Disease of the Heart and Larynx. 291 

irregular, and without force; hands purple; respiration made with 
considerable muscular effort; had a natural evacuation in the night; 
tongue moist and clean; sense of extreme exhaustion; mind clear; 
had the morning papers read to him; stimulants continued, with 
nourishing soups. 5 P. M. Had during the day several fainting and 
sinking spells; is then covered with cold sweats; pulse scarcely per- 
ceptible. The following mixture prescribed: — Sulph. quiniee, gr. 
xij.;Elix. vit. gss.; Syrup zingiberis, ^ss.; Aq. fluvial, §iss.; one 
drachm every hour. Stimulants continued. 10 P. M. Appears to 
have rallied in some measure; fingers less purple; pulse more distinct. 

5th. A more tranquil night; has a feeling of more force; circulation 
improved; had the newspapers read to him this morning; is constant- 
ly in semi-erect position supported by pillows; stimulants diminish- 
ed one half; nourishing soups. 10 P. M. Has continued in better 
state during the day. 

&th. Disturbed in the night by a fire that occurred in the vicinity; 
was much agitated, and lost his sleep; the disposition to sinking and 
fainting was renewed and increased; stimulants again resorted to and 
increased; had three passages during the day, each perfectly natural; 
rallied in the day, and had augmented thirst; stimulants withdrawn 
entirely, and small pieces of ice held in the mouth to allay thirst. 

7th. Rested well; has more force; has used no stimulants dur- 
ing the night; tongue has become red, with white fur; thirst in- 
creased. In evening prostration; respiration laboured; pulse flutter- 
ing; solution of sulph. quinse and toddy renewed. 10 P. M. No im- 
provement; carb. ammonias and wine-whey. 

8/A. Restless night; but little change; tongue moister; had three 
stools in night, all natural; pulse small, feeble, irregular; veins turgid 
with blood that cannot be forced along them; respiration hurried, and 
irregular; stimulants continued; frictions on the spine, with ol. succin. 
R. Spts. camph.; ol. terebinth and ol. succin. m. j. every two hours. 

^th. Tolerable night; symptoms nearly the same; has appetite; sti- 
mulants withdrawn, except spts. Camphor, m. ij. every two hours. 
Evening. In same state. 

IQth. In the night became hoarse, with feeling of soreness in the 
throat; an obstruction there causes difiBcult respiration, and nearly 
prevents swallowing. On examining the throat, the whole fauces 
were tumid; the uvula swelled and thickened; the velum and soft palate 
pressed down like an inflated bladder; very slight redness; skin 
warmer than it has been, and pulse possess more force. Sinapised 
poultice applied to the external surface of the throat; gargle of infu- 
sion of Cayenne, and of a solution of iodine alternately used every 



292 Jackson's Case of Disease of the Heart and Larynx, 

fifteen minutes; punctured the swelled and tumid velum; a thin fluid 
oozed from opening. 1 P. M. Difficulty of respiration and suftbcat- 
ed feeling increased; applied saturated solution of nitrate of silver to 
the fauces, and again punctured the swelling; swallowed some wine 
gruel with tolerable ease, and had appetite. 4 P. M. Swelling of 
fauces greatly augmented; respiration suffocating. The danger of 
suffocation had become so imminent I sent for a surgical friend to 
perform tracheotomy as the only recourse, and in the mean time punc- 
tured freely the tumour, filling up the fauces. A thin bloody fluid 
issued in large quantities, but without relief. Suffocation progressed 
every instant; longer delay was inadmissible, and with no other instru- 
ment than a pocket scalpel I attempted the operation. On making 
the incision through the skin, a thin bloody serous fluid was found 
existing in the cellular tissue, from which it discharged in a copious 
stream. A small opening only was accomplished in the trachea, into 
which the infiltrated cellular fluid was sucked in inspiration. Suf- 
focation was completed, the patient's head fell over, the face bloated 
and blackened, and in a moment he expired. Half an hour only had 
elapsed since I had entered the room, so rapid had been the progress 
of the oedematous effusion. 

The autopsy was performed by my friend. Dr. Mutter, to whom I 
am indebted for the following statement of the condition of the organs. 

Autopsy^ twenty -four hours after death, — Present Drs. S. Jackson 
and GoDDARD. 

Exterior. — The whole of the thoracic portion of the trunk anteriorly, 
and of the thoracic and dorsal portions posteriorly, as well as the su- 
perior extremities as far down as the elbows presented a singular 
mottled and speckled appearance. The discoloured spots which varied 
in size from a line or two in diameter up to that of a space some 
inches in extent, were of a mulberry red colour, and resembled very 
much the common petechial blotch. This peculiarity of the surface 
did not make its appearance until some hours after death, and (as we 
shall see directly,) depended upon the effusion of a bloody serum in 
the cellular tissue of these portions of the trunk; that of the dorsal 
region was owing also in part to the gravitation of the blood, and is 
generally present to a greater or less degree in almost all cases where 
the body has rested upon the back. Tympanitic distention of the 
abdomen existed to a trifling extent; considerable degree of embon- 
point; small incision along the front of the larynx made in perform- 
ing the operation of laryngotomy; no rigidity of the muscular system 
observed; little or no foetor exhaled by the corpse. 

Neck, — The anterior portion of the throat particularly presented the 



Jackson's Case of Disease of the Heart and Larynx, 293 

mulberry red colour of the upper parts of the trunk. Upon making 
an incision through the integuments along the front of the larynx and 
trachea, in order to dissect out these organs, there occurred a copious 
flow of a thin dark bloody serum, contained in the cellular tissue. As 
we advanced in the dissection, the flow of this fluid became so copious 
as to materially retard the operation, and it was necessary at each 
stroke of the scalpel to apply the sponge. We found it diftused not 
only through the superficial cellular tissue, but also in the more 
deeply seated, even indeed down to the spine. In proportion as it 
escaped, the parts assumed a normal colour. 

Larynx. — The cellular tissue of the larynx, both externally and in- 
ternally, was oedematous to a great extent. Externally it was filled 
with the bloody serum already alluded to^ internally with a transpa- 
rent one. The internal oedema commenced at the apex of the epi- 
glottis cartilage, and extended below the vocal cords, and varied in 
thickness from one to six lines. The areteno-epiglottoid doublings, 
and the cellular tissue surrounding the arytenoid cartilages, were the 
points at which the oedema was greatest. Such was the degree of 
their distention, that the superior orifice of the glottis was almost en- 
tirely closed up; (Plate I, Fig. 1, shows this condition of the parts 
very well,) laying open the larynx, we found the oedema so exten- 
sive, that the rima glottidis was completely closed by it, when the 
parts were put in situ. The ventricles of Morgagni were almost 
entirely obliterated, (see Plate I. Fig. 2, for a correct representation 
of the appearances presented by the larynx.) The lining membrane 
of both larynx and trachea, presented a perfectly healthy appearance. 
The fauces and soft palate were likewise perfectly normal. The 
cartilages also exhibited no marks of a pathological condition. The 
immediate cause of death in this case, was the condition of the larynx 
just described, which prevented the introduction of air in sufficient 
quantities into the lungs. 

Thorax. — Finely developed, and well arched anteriorly; sound on 
percussion normal on both sides, with the exception of the anterior 
inferior portion of the left, where it was flat. Petechial appearance 
of the surface; costal cartilages ossified. The incision of the inte- 
guments was followed by a copious flow of bloody serum. Upon 
raising up the sternum and costal cartilages, the anterior mediasti- 
num was found to contain some fatty matter, and to be considerably 
dilated towards its cardiac portion. The pericardium occupied a 
much larger portion of the left thoracic cavity than usual, and also a 
large portion of the right; its posterior surface was glued to the dia- 
phragm by strong short cellular tissue for some distance; it contained 

25* 



294 Jackson's Case of Disease of the Heart and Larynx. 

about ^ij. of a straw-coloured serum, and was lined by a false mem- 
brane, (which was nearly general, though most perfect tovv'ards the 
apex of the cavity,) about one or two lines in some places in thick- 
ness, of considerable firmness, and very adherent. Besides this lining 
there existed several bands of organized lymph, varying in length 
from two to five lines, and very strong, which passed from the peri- 
cardium to the heart, and bound the two firmly together^ so that the 
motions of the heart during life must have been materially impeded. 
Neither the external nor internal layer of the pericardium appeared 
at all thickened or otherwise diseased. The surface of the heart in- 
stead of presenting its usual glossy and shining appearance, was rough, 
and of an orange or straw colour. This appearance was due to the 
existence of a false membrane, similar in most respects to the one 
lining the pericardium. It was nearly as general, and seemed upon 
minute examination to consist of two portions, one firm, homogeneous, 
and about a line in thickness, adhered very closely to the heart; into 
this layer the fibrous bands alluded to, seemed, (if I may be allowed 
the expression,) to be inserted; the other or outer layer was softer, 
of a deeper orange tint, about half a line in thickness, and somewhat 
mamelated. The heart itself much exceeded its ordinary dimen- 
sions, it nearly equalling in size that of a twelve months' old calf; 
its colour was entirely normal, and its consistence a little softer than 
usual. Commencing with the right auricle, we proceeded to the ex- 
amination of its cavities. 

Right *duride. — The right auricle was considerably dilated, and 
its parietes somewhat hypertrophied, particularly those portions 
forming the walls of the sinus. At this point they were about two 
or three lines in thickness. Between the musculi pectinati, and 
sprouting, as it were, from the lining membrane of the auricle, we 
found several tumours, varying in size from the head of a pin, up 
to that of a large bean, of a peculiar shape, and whitish or light pink 
colour. They were generally spheroidal, but presenting a number of 
facets, which gave them a shrunken or shrivelled appearance. They 
were attached either by a narrow pedicle, or by several cords, none of 
them had an extended base. When cut open they were found to 
consist of a whitish, somewhat firm capsule, about half a line thick, 
containing a reddish-gray, semi-fluid mass, which resembled very 
much disorganized blood, or the thick lees of red wine. The cap- 
sule seemed to be perfectly organized. They were situated chiefly 
along the upper portion of the sinus, or that part nearest the base of 
the heart; there was one, however, (the largest met with in this 
cavity,) attached to the anterior division or flap of the tricuspid 
valve; it equalled in size a large filbert, and must have materially 



ackson's Case of Disease of the Heart and Larynx, 295 

interfered with the venous circulation. See Fig. 4, which represents 
the sinus of right auricle laid open, and of two-thirds of the portion 
of the tumour situated on the interior flap of the tricuspid valve. 

Fig. 4. 




Right Ventricle. — This cavity was filled with a black coagulum, 
which extended into the orifice of the pulmonary artery, it was some- 
what enlarged, though not to so great an extent, comparatively 
speaking, as the other cavities of the heart; its parietes were slightly 
hypertrophied, and of a healthy consistence. The columnae carneas, 
as well as the chordae tendinse, were also much larger than usual. 
At the most anterior angle of the cavity, and in that portion of it 
forming the anterior wall of the heart where this viscus is in situ, 
there was a large group of tumours, resembling in every respect 
those already described as existing in the auricles, they were how- 
ever, much larger than the former, and were partially concealed by 
the columns, by cutting out one or two of them; the larger portion of 
the collection was distinctly brought into view. (See Fig 5, exhibit- 
ing a section of the apex of the heart; cf, right ventricle; b, left ven- 
tricle; c, inter-ventricular septum; f/, rf, tumours.) The orifice of 
the pulmonary artery, as well as its valves, presented a dull red 
colour. The valves of the ostium venosum, with the exception of 
the anterior one, were flexible, and every way normal. 



296 Jackson^s Case of Disease of the Heart and Larynx, 

Fig, 5. 




Left Auricle, — The left auricle was dilated, and its parietes 
slightly hypertrophied. None of the tumours described were met 
with in this cavity; orifices of the pulmonary veins not inflamed. 

Left Ventricle — This cavity was also dilated, though its parietes 
were not hypertrophied; some of the columns seemed larger and 
more firm than usual. In that portion of the cavity, which forms 
the apex of the heart, there were several tumours found, resembling 
those met with in the right cavities. The largest tumour found in 
the heart was situated at this point, and equalled in size a large 
English walnut; it was rough on the surface, and contained a fluid 
similar to that found in the others, (see Fig. 5.) The valvula mitra- 
lis was perfectly normal. The orifice of the aorta, as well as the 
aortic valves, presented a dull red colour, similar to that met with 
in the pulmonary artery. 

Arteries, — The lining membrane of the aorta, commencing at its 
orifice, and extending to some distance below its curvature, was 
covered by a layer of coagulable lymph, about half a line in thickness, 
and apparently of recent formation, as it could be detached from the 



Jackson's Case of Disease of the Heart and Larynx, 297 

subjacent serous coat with great facility; its surface was perfectly 
smooth. Upon raising this up, the serous coat of the artery presented 
the appearances of an acute inflammation, manifested by its bright 
and permanent vermilion hue, its increased thickness, and by the 
gradual termination of the redness some inches below the arch. The 
valves, at their bases alone, were covered by the false membrane. 
The pulmonary artery presented the same morbid phenomena. The 
occurrence of this albuminous exudation upon the surface of the 
serous coat is considered by Baillie, Laennec, ANDRAL,<jrENDRiN, 
Guthrie, &c. as the most positive indication of the previous existence 
of inflammation, (see Plate I. Fig. 3.) 

Abdomen. — The viscera of the abdomen, without exception, were 
found in a perfectly normal condition. 

Brain and Spinal Marrow. — From the lateness of the hour at 
which the post mortem was made, these viscera were unavoidably 
passed over without examination. 

Observations, — From the preceding facts, it appears that dilata- 
tion and a slight hypertrophy of the right pulmonary heart existed; 
the species of hypertrophy denominated by Bertin excentrick hyper- 
trophy. The lining membrane was slightly injected, but had none 
of the more positive signs of active inflammation. The most re- 
markable and peculiar pathological feature, were the tumours existing 
in the different cavities. They are of rare occurrence, and their 
origin is involved in much obscurity. Laennec first clearly indi- 
cated a lesion of this character, which he describes under the appel- 
lation of globular vegetations, (Traite de I'Auscultation, vol. ii. p. 
630.) The only difference between the globular vegetations of 
Laennec and those of the present case, exists in the exterior cover- 
ing. He describes them as small, spherical, or ovoid balls or cysts, 
from the size of a pea to that of a pigeon's egg; the exterior surface 
being smooth, equal, and of a yellowish white. In this case the ex- 
terior surface presented numerous facets, and bore a strong resem- 
blance to the crystallization of the garnet. In other respects the 
description of Laennec tallies precisely with the appearances ob- 
served in the specimen of this case. 

The origin of these tumours it is not possible to trace with cer- 
tainty; they have the aspect of a coagulum of blood, enclosed in an 
organized cyst, and partially organized itself; but how this should 
occur, our present knowledge does not enable us to form a conjec- 
ture. Polypi-form concretions of the blood are of very common oc- 
currence in the heart, and are often the cause of great embarrass- 
ment to the circulation, and finally of death. These concretions, at 
times, appear to acquire a certain degree of organization, jet they 
are very different in form and character to the globular vegetations. 
It is safer at present to refrain from all conjectures on this subject. 



298 Jackson's Case of Disease of the Heart and Larynx. 

In the foregoing case a circumstance of interest also was present. 
Acute pericarditis existed, as was ascertained by the autopsy. But 
during life it was manifested by no positive diagnostic signs. The 
irregularity of the contractions of the heart exist wholly independent 
of pericarditis. I saw a gentleman in a consultation visit this spring, 
whose heart acted in the most irregular manner, with very feeble con- 
tractions. He died soon after quite suddenly from apoplexy. The 
pericardium, whose inflammation I had suspected to be the cause, 
was reported to me to be healthy, but the substance of the heart 
was softened, and an ulcer existed in its parietes. 

In this case no fever, or acute pain, the common attendants on 
acute pericarditis, were present. The mind too so often disturbed 
with agitating fears in that disease, was perfectly calm and tranquil. 
From the obscurity of the symptoms I felt entirely at a loss to de- 
termine the true diagnosis 'of the affection. A cardiac lesion was evi- 
dent, and a difficulty in the course of the circulation was apparent, 
but the precise nature of either could not be determined. 

On a review of this case, I feel at a loss in deciding whether it would 
have been a preferable course to have attempted blood-letting for the 
relief of the circulation, notwithstanding the strong evidences of de- 
bility, instead of stimulating. From the apparent effects of the stimu- 
lants, they were indicated. The symptoms were lightened, and be- 
fore the effusion occurred, a very positive amendment had taken place. 
But was not the effusion one of the effects of the stimulants? Yet 
why should their action be so local as to affect exclusively the throat? 
These questions it is difficult to solve. 

Aortitis also existed in this case, yet no signs were present to in- 
dicate its existence. The pulse in this form of disease is usually tense 
and hard. The irregularity and feebleness of the heart's action may 
have controuled this symptom, usually produced by arteritis. 

The immediate cause of death appears entirely unconnected with 
the cardiac lesions. The symptoms originally present, and indica- 
tive of disease in the central organ of the circulation had been yield- 
ing; a decided amelioration had taken place, when without any as- 
signable cause, the cedematous condition of the fauces and neck en- 
sued, extending to the larynx. 

That the cause was local is evident from the oedema having been 
limited. In the external cellular tissue the effused fluid was 
deeply coloured with blood. 

I have met with several cases previous to this, of oedema of the 
fauces of a lighter degree, and producing very suffocative respiration, 
showing its extension to the glottis. They all recovered. This is 
the first instance I have seen of the disease in a fatal form. 



Waddel on Diseases of the Sympathetic Nerve. 299 



Art. II. On the Mechanism of some Diseases of the Sympathetic 
Nerve. By W. W. Waddel, M. D. [Communicated by Pro- 
fessor Dickson, of Charleston, S. C] 

[To THE Editor. 
Dear Sir — I send you the following ingenious essay, which was 
handed to me by the writer two years since for perusal. Being ex- 
tremely pleased with it, I solicited a copy for your Journal, a request 
with which my friend Dr. W. has at last been induced to comply. 
Those who are fond of close observation, and free but cautious induc- 
tion, will be amply repaid for the time spent in reading it, by finding 
here more original remark and scientific reasoning than are often 
compressed within similar papers. 

Yours, &c. S. H. Dickson.] 

X HE important subject which forms the basis of the present paper, 
will be presented to the reader in a series of somewhat desultory re- 
marks, rather than in the form of an artificial and connected treatise. 
This course will disclose, so far as consistent with proper perspicuity, 
that train of observation and reflection, which led to the adoption of 
the views herein advocated. Those views will be best elucidated by 
commencing with the history of a most melancholy case, which excited 
deep and extensive interest in the region of country where it occurred. 
Mr. H. a distinguished lawyer of Athens, Georgia, died in the 
month of October, 1830, affected with paraplegia. He was rather 
tall and spare in person, pale in complexion, phlegmatic in tem- 
perament, and at the time of his death, about thirty years of age. 
None of his family ascending, descending, or collateral, have ever 
been peculiarly disposed to hereditary disease; indeed they are said 
to have enjoyed remarkable immunity from all kinds of chronic dis- 
order. Before his marriage, about the year 1823, he was studious 
and sedentary in his habits; after that event he became more active. 
It was about this time that he began to complain of cardialo-ja, 
nervous head-ache, pain at the point of the scapula, and possibly 
some other symptoms of derangement in digestion. Two or three 
years afterwards, whilst on the circuit, attending one of the upper 
county courts, he slept in very damp sheets, and had all these symp- 
toms highly aggravated. From this time onward, dyspepsia and hy- 
pochondriasis, with their ordinary accompaniments, made silent but 
constant progress. In April, 1829, he found himself somewhat 
wanting in ability to void the contents of his bladder; and this was 
the first symptom of paralysis. It may be proper to remark, that 



300 Waddel on Diseases of the Sympathetic Nerve. 

hitherto his bowels had acted well, and that he was not at all troubled 
with pain, either in the epigastric or hypochondriac regions. In 
August he first remarked that he was losing sensation in the soles of 
his feet, and this was followed by a similar loss in the calves of his 
legs, numbness of the thigh, and weakness of the lower limbs gene- 
rally. Being a candidate for the state legislature, he attended the 
election at the County Court House, seven miles from home, about 
the first week of October. Here his strength was much exhausted 
by the exercise, and the excitement which probably attended on a 
successful convass. Riding home on horse-back the next day, he 
was seized with pains in the lower part of his spine, and spasms in 
the neighbouring muscles. He now soon lost sensation and motorial 
power in both of his lower extremities to a great degree. The tem- 
perature of his diseased limbs was variable. 

Just at this period the author of this essay was requested by his 
family physician to see him. He had been taking some aperient and 
alterant medicine, and no particular change being instituted in the 
treatment, he shortly determined on being carried to Milledgeville, 
a distance of seventy miles, to meet the State Medical Board as a 
council on his case. On his way, an application of tartar emetic 
ointment was made to his legs, which produced very angry effects, 
and threatened something like gangrene. 

Being arrived in Milledgeville, he underwent a course of treat- 
ment for fever with which he was attacked, and had two issues esta- 
blished in his back by the council called to him. This was followed 
by immediate melioration of his symptoms, and onward from that 
time, an indefinite number of issues were kept discharging until 
within two months of his death. 

His absence from home amounted to five weeks, at the expiration 
of which time he was brought back, apparently much improved in 
general health. His appetite in the course of a week became very 
vigorous, soliciting food of the strongest kind. Some indulgence of 
this propensity invited a return of his fever, but no symptom of mo- 
ment appeared until February of 1830, when he was seized with 
universal muscular spasms of a very severe character. Colic, 
throughout the whole of his illness, was one of his most distressing 
symptom, and this was accompanied by a great evolution of gas, and 
so much spasmodic uneasiness, as to threaten the extinction of life. 
For this he commenced the use of laudanum as the spring advanced, 
and gradually increased its dose until, within a few weeks of his 
death in October, at which time he would take as much as two ounces 
and a half in twenty-four hours. 



Waddel on Diseases of the Sympathetic Nerve, 301 

A visit to a chalybeate spring in May, did not materially benefit 
him. Great emaciation of the lower extremities, together with per- 
manent tonic contraction of the flexor tendons of the toes came on, 
and paralysis gradually extended upwards untilJuly, when sensation 
became null as high as the xiphoid cartilage in front, but not so high 
on the posterior part of the trunk. During the summer his bowels 
were irregular; the power of the sphincter ani was lost, and also the 
sensibility of the rectum, as high as the sigmoid flexure of the colon. 
He received intimation of an approaching alvine discharge, by a sen- 
sation in his bowels similar to what might be expected from warm 
water passing through them. He sometimes had power to retain and 
void the contents of his bladder ad libitum; at other times all controul 
of the vesical sphincter was lost, and the urine was discharged in- 
voluntarily. It was sometimes bloody, at other times it came away 
mingled with long shreds of mucus; during the latter part of his life, 
it consisted in a great measure of pure blood. 

His treatment under the care of Dr. Linton for the last two 
months of his life, consisted in drying up his issues, regulating his 
bowels with sulphate of alumine, calcined magnesia, &c. &c. Infu- 
sion of hops was substituted for tincture of opium, and the latter 
article was withdrawn entirely, so far as practicable. Moxibustion 
was instituted on his spine, feet, and knees. To the use of the latter 
remedy, there succeeded a development of very obscure sensation in 
the sole of one foot, and in the ankle of the opposite limb, together 
with a perceptible relaxation of the flexor tendons of the toes. 

Three weeks previous to death, a pain commenced in the right 
hypochondrium, attended by some spasmodic movement of the cor- 
responding external part, which was intermittent in character. 
Seventy-two hours before death, there issued from his bowels a pro- 
fuse sanguineo-purulent discharge, followed by great prostration of 
vital power, inability to swallow, dimness of vision, and death in the 
entire possession of every intellectual faculty. 

Warmth was general throughout his lower limbs until the last 
moment. 

Jititopsy, sixteen hours after death. — Present, Drs. Linton, Jones, 
TiNSLEY, and Waddel; and Messrs. Marshall and Franklin, 
medical students. 

External aspect. — The body presented the utmost extreme of 
emaciation, but this was much more remarkable in the lower limbs 
than elsewhere. The different notches and processes which consti- 
tute the contour of the pelvis, were boldly pronounced, and plainly 

No. XXX.—February, 1835. 26 



302 Waddel on Diseases of the Sympathetic Nerve. 

seen through the external integuments; the muscles of the limbs were 
reduced to strings, and the anterior walls of the abdomen were in 
contact with the spinal column. The blood, from the position of the 
body, had gravitated to the back, and the posterior periphery of the 
trunk presented a generally ecchymosed aspect. The burnt spots 
occasioned by the use of the moxa, had been obstinate in refusing to 
heal previous to death. Externally they seemed to be gangrenous, 
but dissection of the integuments showed that disease in those places 
did not extend below the cutis vera,, proving a want of vital power in 
the integuments alone to be the cause of their unhealthy character, 
and exemplifying, probably, the attribute of the cellular tissue men- 
tioned by BicHAT, of insulating and preventing the extension of dis- 
eased action. 

Spine, ^c, — The tegumentary and muscular parts being removed 
from the vicinity of the vertebral column, the bony arches of the 
vertebrae were detached with the chisel and mallet, commencing 
about the middle dorsal vertebra, and proceeding downwards. All 
the bones were found to be perfectly sound in structure, so much so, 
as to cause considerable difficulty in breaking through their con- 
nexions by force. The lower section of the spinal cord was taken 
out and examined, both before and after washing. There was no 
manifestation of disease, either in the medulla propria or its investing 
sheaths; no vascular engorgement, nor any departure from proper 
consistency or healthy colour, so far as the judgment of the profes- 
sional gentlemen present could be relied on. 

Abdomen. — On making the necessary incisions, and turning back 
the flaps, the whole mesenteric venous circle was beautifully dis- 
played in the form of a dark injection. The liver, spleen, mesen- 
teric glands, and right kidney, were externally healthy; the left kid- 
ney was not examined. The stomach was somewhat contracted, and 
partly filled with a fluid resembling dark blood, but tinged with the 
rich hue of healthy cystic bile. Its mucous lining presented the 
most intense grade of dark red injection, and this not in pathes, but 
generally and equally diffused. The colour of the same tissue in the 
small and great intestines did not essentially differ from that in the 
stomach, but instead of finding those organs filled with a similar 
fluid, their walls were found bathed in loose purulent matter, of a 
dirty yellow hue. The source of this was discovered to be an ulce- 
rated perforation of the duodenum, not far from the antrum pylori, 
the edges of which were soft and ragged. The diameter of the per- 
foration was about half an inch. 



Waddel on Diseases of the Sympathetic Nerve. 303 

Thorax. — This cavity contained nothing worthy of record, but a 
remarkable diminution in the size of the heart, and a manifest pale- 
ness of the lungs. 

The character of the preceding history and autopsy no doubt re- 
quires apology. The author would say, that it was only during a 
short time that he constituted a part of the medical council in the 
case of Mr. H. and that^ near to the termination of his life. He is 
not aware of any journal having been kept by his former medical at- 
tendant, and the history is principally made up of excerpts of infor- 
mation communicated by Mr. H. and his lady. This may account 
for an appearance of unnecessary minuteness in some respects, and 
too great generalization in others. A very limited time was allowed 
to prosecute an examination post mortem, and this was consumed in 
taking a rapid survey of the most important organs. It is much to 
be regretted that we could not examine the intra-cranial mass, and 
the ganglia of the sympathetic nerve. The interior of the bladder, 
kidneys, liver, spleen, &c. were all overlooked for want of time. 

When we undertake an investigation into the nature of the exten- 
sive malady which is portrayed in the foregoing history and autopsy, 
we are called upon first to examine the predominant manifestion — 
paraplegia. If we shall be able to trace the connexion of this symp- 
tom with the internal structural disease, and at the same time ac- 
count for the coexistence of a clear intellect and a perfectly healthy 
spinal cord, it will be well; but if not, there are few who will not 
acknowledge the complications of diseased action to be so strange, 
that no discredit can be attached to a failure. The author of the 
present essay desires to approach his subject with that degree of 
modesty, which becomes even the most learned and experienced, in 
attempting to solve the mysteries of the nervous system. Many 
praiseworthy efforts of this kind have been made of late years, and 
much light has been concentrated on an obscure and interesting topic. 
But wheh it is considered that we are yet in the infancy of our 
knowledge respecting this department of pathology, it is to be hoped 
that the humblest contribution may not be without its value. 

It is notorious that a pathological condition of the spinal cord, or 
of some portion of the bony or ligamentous structure of the vertebral 
column, was long thought to be the cause of paraplegia. Of late 
years, however, a galaxy of distinguished men have lent the influence 
of their names to the idea, that it more frequently originates from 
derangement in some part of the brain. Dr. Baillie, Dr. Aber- 
CROMBIE, Dr. Cooke, Sir James Earle, Sir Henry Halford, and 
Mr. Copeland, are all quoted as having concurred in this opinion. 



304 Waddel on Diseases of the Sympathetic Nerve. 

It is probable that the earliest and most satisfactory description of 
this form of paraplegia, is to be found in the paper of Dr. Baillie, 
"Upon Paraplegia in Adults," in the sixth vol. of the Medical 
Transactions of the London College of Physicians. It will early 
strike the reader in reflecting on the great extent and varied nature 
of the disease recorded in the present instance, that had it taken its 
origin from any disorder of the brain, we must almost of necessity 
suppose, that it would have been preceded, accompanied, or fol- 
lowed by some derangement of the more immediate functions of that 
organ, and more especially of the intellect. Dr. Cooke, in quoting 
Dr. Baillie, has the following language confirmatory of this idea. 
"It,'' (cerebral paraplegia,) "is accompanied either by some feeling 
of pain, or giddiness, or sense of weight in the head, or undue drowsi- 
ness, and vision is often more or less impaired^ sometimes the sight 
of one eye is almost entirely lost, and its pupil appears dilated, as in 
gutta Serena, and occasionally there is a paralytic dropping of the 
upper eyelid of one eye; sometimes the affection of the brain is 
marked by a defect in the memory, and a want of the ready exercise 
of the general powers of the mind; sometimes one or both of the upper 
extremities are affected more or less with numbness, and with a fee- 
bleness of their motions, when no disease whatever can be found in 
the cervical part of the spine. These circumstances. Dr. Baillie 
thinks, afford strong evidence that the cause of the disease exists in 
such cases, within the cavity of the skull, and that it consists in some 
mode of pressure on the brain."* 

We derive strong proof that cerebral paraplegia necessarily in- 
volves some mental derangement, from the statistics of general para- 
lysis, as it occurred under the observation of Dr. Calmeil, in the 
Royal Lunatic Asylum of Charenton. In his work,t about fifty of 
the sixty-four cases of general paralysis recorded, were preceded by 
mental alienation; in a very few instances the paralysis was the pre- 
cursor; in a small number, constituting a third class, the two diseases 
manifested themselves simultaneously; but no case came under 
notice, where the mental disorder was not present sooner or later. 
The motions of the tongue and pelvic members were almost uniformly 
first affected after the symptoms of intellectual disease appeared; the 
paralysis of the arms was in general a phenomenon of later occur- 
rence. Hemiplegia appears to have been rare. Dr. Calmeil regards 
it " as a thing impossible, that reason can long remain untouched, 
when the brain is so profoundly affected as it is accustomed to be in 

• On Nervous Diseases, p. 241. f De la Paralysie considdr^e chez les Alien^s. 



Waddel on Diseases of the Sympathetic Nerve. 305 

the case of general paralysis."* Again, "it is very rare that the 
material lesion commences in that part of the encephalon from 
whence the powers of motion derive their origin, the part which pre- 
sides over the manifestations of intellect at the same time remaining 
sound, "t In recurring to the history of Mr. H. we shall be struck 
with the remarkable difference between the picture exhibited by his 
malady, and the symptoms as detailed by the above authorities. He 
was never affected by any aberration of function in his brain or upper 
extremities. So perfect was his intellect, that one of his brother 
lawyers was in the habit of availing himself of his counsel to assist 
in unravelling knotty cases in law, after his confinement to bed be- 
came constant. These facts, added to the perfect preservation of a 
sound mind to the latest hour of life, speak for themselves, so far as 
any implication of his brain might be suspected. 

It is possible that some one might urge, that the absence of intel- 
lectual derangement can only be conclusive of the integrity of the 
cerebral hemispheres; and inasmuch as the examination of the whole 
intra-cranial mass was neglected for want of time, there might still 
be an altered structure or other pathological condition of the cere- 
bellum. It is difficult to say what is satisfactorily known relative to 
this part of the encephalic apparatus. Some physiologists, however, 
have concluded it to be the source of that power which combines and 
coordinates motion, and not the source of motion itself.:}: In the pre- 
sent case it may have still preserved the integrity of its functional 
powers, but they were not so much called into exercise, because no 
motions of the lower limbs were executed, requiring coordination. 
Mr. H. retained the most perfect command of his upper extremities, 
and no discovery was ever made by his physicians or attendants, to 
the effect that he had ever lost his combining power over their motions 
in the smallest degree. 

It was suggested by a gentleman at the post mortem examination, 
that the intervertebral fibro-cartilages were much thickened and en- 
larged. This was no doubt due to the patient's almost constant de- 
cubitus for the previous twelve months, in the course of which time, 
these bodies, from the removal of all superincumbent weight, had ex- 

• P. 8. -f P. 339. 

\ Amongst all the experiments of the vivisectors on the cerebellum, those of 
Bouillaud appear to point out most plainly the physiological uses of that organ. 
It seems that injuries inflicted on it never caused loss of power of flexion or ex- 
tension, nor yet loss of general muscular energy, neither did they produce con- 
vulsions or paralysis, local or otherwise; but they uniformly resulted in an ia- 
capacity to combine the actions of the motorial apparatus. 

26* 



306 Waddel on Diseases of the Sympathetic Nerve, 

panded and permanently lost their elasticity. Those who have at- 
tended the anatomical lectures of Dr. Physick on the spinal column, 
may remember to have seen him push a scalpel into the fibro-cartilage, 
and that when the hand is removed, the knife is extruded by the 
elasticity of the compressed pulpy matter in the centre of the struc- 
ture« In the present case this experiment was tried on two car- 
tilages, but no motion of the knife followed. Elasticity, as much a 
property of dead as of living matter, was entirely gone, and we are 
left to conclude that the expansion was a natural and legitimate re- 
sult of a simple cause acting on the structure, long after paralysis had 
already taken place. 

The reader might probably be willing to rest the general argument 
against the existence of disease of the spinal cord in the case under 
consideration in this^ that from the middle dorsal vertebras down- 
ward, there was no discoverable change in its organic structure, not- 
withstanding a paraplegia which was complete for nearly one year. 
Before we come to such a conclusion, let us examine the opinion of 
one who has had much experience on the subject. M. Calmeil in a 
long list of post mortem appearances found in the bodies of those dead 
of paralysis and mania, gives the following: — injection of the cranial 
bones and of the dura mater^ general meningeal infiltration; accu- 
mulations of serosity betwixt the opposing surfaces of the arachnoid 
tunic; mollescence, hardening, injection, and other changes in colour 
and consistence, both of the white and gray substance; pseudo-mem- 
branes, organized and non-organized, together with sanguineous cysts, 
between the surfaces of the arachnoid tunic; vegetations of the pia 
mater; thickening of the same membrane; adhesions betwixt the pia 
mater and the cerebral convolutions; softening of the spinal cord, 
&c.* Notwithstanding a majority of the cases of general paralysis in 
maniacs related by M. Calmeil, left post mortem record of the above 
manifestations, he contends that they are neither necessary to the pro- 
duction, nor sufficient to the explanation of the symptoms during life. 
He comes to the conclusion that it is a chronic phlegmasia of the 
brain which gives rise to general paralysis, by determining in that 
organ a certain modification which we have not hitherto known how 
to appreciate. And if there happen a case where the brain after death 
presents no trace of such a phlegmasia, it must not be received as 
certain proof that it had not preexisted, but we are to suppose that it 
had lasted sufficiently long to result in paralysis, and had subsequent- 
ly disappeared, the paralysis remaining. The phlegmasia alluded to 

• De la Paralysie, &c. p. 415. 



Waddel on Diseases of the Sympathetic Nerve, 307 

is a thing entirely independent of the alterations mentioned above. 
We are thus thrown back on the very vague and unsatisfactory doc- 
trine, that in paralysis, we are not to expect any sensible alteration 
in the structure of the great nervous centres after death, notwith- 
standing the many autopsies which go to prove a coexistence of the 
alterations with the symptoms during life. We must either protest 
against such a doctrine or confess that post mortem examinations in 
such cases are almost useless. In reference to the case of Mr. H. 
reasons have already been given for supposing the brain free from imt- 
plication^ and from the length of time occupied by the symptoms, had 
the disease originated in the cord, we should have had good reason 
to expect that autopsy would have revealed to us atrophy, moUes- 
cence, meningeal injection, or some other important structural change 
in that organ. The reader has already been told that none of these 
were found. 

Driven from the idea that the paralysis had any direct connexion 
with the brain or spinal cord, it is not difficult to determine that it 
was the result of an aggravated disease of the stomach and bowels, 
to which it stood in the relation of a secondary effect. Authors have 
spoken of such a form of disorder before, though very obscurely, and 
we may now examine the amount of information to be gathered on the 
subject, from a common medical library. 

It is believed that the credit is due to Mr. Abernethy of having 
first called the attention of the profession to a form of partial para- 
lysis of the lower extremities, originating from a pathological condi- 
tion of the digestive organs. He relates five or six cases of this cha- 
racter,* several of which were cured by country air, exercise, re- 
gimen, and a few simple medicines. So far as we can learn from 
reading his reports, he believed that those cases were due to a dis- 
order of the nerves and some circumscribed portions of the spinal 
cord, (spinal centres of Le Gallois,) independent of the brain. It 
is palpably clear that all his notions eventually result in supposing a 
disease of the cord, to which view we do not subscribe. 

Professor Lobstein in that portion of his work devoted to the pa- 
thology of the sympathetic nerve, relates a case of paraplegia as having 
occurred in a girl ten years of age, accompanied by diarrhoea, with 
incurable tormina and tenesmus, no intellectual derangement being 
mentioned. Dissection revealed a large abscess of the left side, ex- 
tending from the sixth to the tenth dorsal vertebra, which had pro- 
duced complete caries of the sixth and seventh of those bones. Cor- 

• Surgical and Physical Works, p. 61. 



308 Waddel on Diseases of the Sympathetic Nerve. 

responding to this caries, the spinal cord for sixteen lines, was whiter 
than usual, and in a state of atrophy. The intervertebral cartilages 
and the meninges of the cord were sound, but the trunk of the sym- 
pathetic nerve from the sixth to the twelfth dorsal vertebra was com- 
pletely destroyed, and its lumbar portion in a state of inflammation.* 
It seems to have been the object of professor Lobstein in relating this 
case, simply to illustrate the post mortem alterations left after dis- 
eases of the sympathetic nerve. No principle is deduced from it to 
show that paralysis is a probable result of those diseases, nor is such 
a principle to be discovered in his great work. The reader will of 
course observe for himself that there was sufficient lesion of the spinal 
cord to account for the paralysis. 

Broussaist speaks freely of paralysis from chronic internal disorder. 
He notices, however, no especial mechanism. 

Begin, J in speaking of the extensive dominion of the stomach over 
all other parts, remarks, that ''the muscles placed under the influ- 
ence of the nerves, brain and spinal marrow, are generally affected 
through the medium of those organs in gastro-enteritis. They are 
sometimes seized with trembling, convulsions, spasms, tetanus^ at 
other times they experience an irresistable reluctance to motion, and 
a deep sense of weakness and palsy to a certain extent." We have 
here another expression of the pathological fact, but still without an 
exact mechanism^ for we are left in doubt whether M. Begin alluded 
to the sympathetic anastomosing cords, or to the pneumo-gastric nerve, 
brain and s[)inal marrow, as the route by which disease travelled. 

Dr. Geddings, in a paper on the use of strychnine in paralysis, 
in the fourteenth No. of this journal, speaks of the well known fact, 
that that disease results from the influence of lead in the stomach 
and bowels, and indicates the anastomosis of the visceral with 
the encephalo-spinal nerves as the medium by which pathological 
action is extended. The ideas contained in the present paper will 
be found to be very different from those of Dr. G. as the sequel will 
show. 

Amongst the many modifications of doctrine which have of late 
years laid claim to public attention as explanatory of the morbid phe- 
nomena of the nervous system, that contained in the work of Mr. 
Teale, has probably enjoyed in this country the highest popularity. 
At the time the present case was reported to the Central Medical 
Society of Georgia, in December, 1830, Mr. Teale's work not being 

• Lobstein on the Sympathetic Nerve. Pancoast's translation, p. 147. 

■j- Pathology. Prep, cciii. t Therapeutics, translated by Tessier, p. 16&, 



Waddel on Diseases of the Sympathetic Nerve, 309 

in general circulation, it was suggested bj a highly respected medical 
friend, that Mr. T. had reported similar cases, and embraced in his 
speculations similar pathological notions. The reader shall judge for 
himself that this was a great error. The two doctrines will be found 
to offer to view nothing in common; they exhibit nothing but palpable 
contrast. In order to make this plain, the present author would v/ith 
all proper modesty point out what he believes to be the faults in Mr. 
Teale's pathological views. He attributes all the morbid nervous 
symptoms which come under his notice to an original affection of the 
central nervous masses, from which the nerves supplying the diseased 
parts proceed. Let an examination be instituted into the probability 
of this theory. All the great nervous centres are either encased within 
solid bone, or so deeply hid in the recesses of the system, that it is 
impossible for external agents to reach them and produce disease, ex- 
cepting through the medium of the nerves which pass betwixt those 
centres and the tegumentary tissues. Those disorders of the brain, 
(or of other parts, secondary to disorders of the brain,) which pro- 
ceed from the moral affections, do not even constitute exceptions to 
the rule, for all perversions of the moral movements result from 
causes originally introduced through the external senses, the nerves 
of which are exposed to their appropriate stimuli on the tegumentary 
membranes. If such be the truth, it would seem to be a thing impos- 
sible for an original disease of a nervous centre to exist, and we must 
conclude that an irritation of the sympathetic ganglia, of which Mr. 
Teale has spoken, the morbid movement first originates in some one 
of those mucous tissues which are so exposed to countless stimuli, and 
that it is subsequently propagated by the visceral cords of the sympa- 
thetic nerve to the ganglion. 

When we undertake to deduce our therapeutic indications from the 
doctrines of Mr. Teale, we shall find that a belief in them is not 
merely an ideal evil, for it will lead us to make the same mistakes 
that he has made, (and which he professed to avoid,) namely, to ap- 
ply our remedies to the seat of the symptom, rather than to the seat 
of the malady. For example, we may suppose an inflammation to 
commence from the operation of the ordinary causes in the gastro-in- 
testinal mucous tissue, to involve the visceral branches of the sympa- 
thetic nerve, and to be transmitted by them to the ganglia; and even 
more, we may suppose, that by the appropriate anastomosis, a cor- 
responding portion of the spinal cord may become affected. The 
question before us is this: will the remedies of Mr. Teale, (counter- 
irritations to the spine,) though they produce temporary relief, hold 
out any hope of a permanent cure? They are beneficial in the case 



310 Waddel on Diseases of the Sympathetic Nerve. 

of Mr. H. but we have no right to hope that disease will not return 
in every other case, as it did in his, after the effects of the remedies 
have subsided. We must address our remediate agents to the sto- 
mach also, a.nd principally to it, and when it is restored to a healthy 
condition, then, and not till then, will the health of the ganglion and 
spinal cord be permanently restored. 

Mr. Teale has related some cases which are explicable on the prin- 
ciples advocated in the present paper, and the case of the dyspeptic 
married lady may be especially referred to as one of them, (case No. 
13.) He has not, however, resorted to the explanation, and it may 
moreover be remarked that he has said but little of that reciprocal 
sympathy betwixt internal and external life, on which hinges all the 
correspondence of action between the two, and which accounts for so 
much that is obscure in pathology. 

The author would premise his own particular views of the mechanism 
of diseased action in the case under review, by professing his belief 
in the celebrated theory of Keil,* in regard to the nature and uses 
of the sympathetic nerve. Admitting this nerve to stand betwixt the 
visceral surfaces and the encephalo-rachidian apparatus, as an inter- 
medium for the communication of impressions from the one to the 
other, we must, with Keil, look upon it in the character of an isolator, 
a semi-conductor, so to speak, a part of whose office is to benumb and 
deaden the intensity of the vital actions of one class of organs on the 
other. We cannot see it in an agent of/wZ/ conducting capacity, but 
rather a medium of slow and obscure, but sure and steady innervation, 
between the organs of internal and external life. This is its physi- 
ological condition. But in some modifications of its state, and these 
most probably consist in irritation or inflammation, it most evidently 
becomes changed in character, and exalted in function, from an iso- 
lator to a full conductor. Two series of pathological phenomena re- 
sult from this change. The influence of the brain on the stomach and 
bowels, which was formerly broken and benumbed by this nerve, is 
now transmitted rapidly, and hence all those persons who are suffer- 
ing from chronic irritations of the digestive organs have their diseases 
much aggravated by any cause which produces mental emotion. On 
the other hand, the internal movements of digestion, with their de- 
pendent processes, are no longer confined in their impressions to the 
viscera, but those impressions are transmitted to the brain, occasion- 



* It is probable that the best analysis of this theory to be found in a common 
library, is the one given by professor Lobstein in his work on the sympathetic 
nerve. — Pancoasfs translation, p, 72, et seq. 



Waddel on Diseases of the Sympathetic Nerve. 311 

ing great disturbance in the functions of that organ, and hence the 
well known fact, that dyspepsia and chronic irritations of the alimen- 
tary tube, can prostrate the energies of the finest intellect. In all 
these cases it is probable that there is an exaltation, more or less de- 
cided, in the conducting powers of the sympathetic nerve. 

The case of Mr. H. has nothing in it so obscure that it cannot be 
explained on the above-mentioned principles. His first disease was 
dyspepsia and its ordinary concomitant, chronic gastro-intestinal irri- 
tation. By sleeping in damp sheets, (vide history,) this latter was 
exaggerated into inflammation, involving the visceral cords of the 
sympathetic nerve, subsequently the ganglia, and finally the anas- 
tomosing cords. It is not necessary to suppose that the inflamma- 
tion ever proceeded so far as to affect either the spinal cord or its 
envelopes, and indeed there is good reason to determine that it did 
not, since we never knew of the existence of pain in that region 
during life, nor detected alteration of a morbid character after death. 
Understanding then, that in a state of nature, a stream of nervous 
influence passes from the brain into the spinal cord, and by the nerves 
into the limbs, and that a part of the same stream passes by the 
anastomosing cords of the sympathetic nerve to the visceral surfaces, 
is it not probable that the highly exaggerated vitality of that nerve, 
in its inflamed state, caused it to appropriate or monopolize by a spe- 
cies of revulsion, too much, nay, all of that innervation, proceeding 
from the brain, and originally designed for the teguments and mus- 
cles of the lower limbs? If such be the fact, we are to look upon the 
sympathetic nerve to have had its conducting capacity so elevated by 
disease, that it acted the part of a diverticulum of the nervous prin- 
ciple from its proper destination, leaving us no reason to be surprised 
that the parts from which this principle was abstracted should become 
paralytic. 

Amongst some notes taken about the time that Mr. H. died, the 
author finds the following fact communicated by Dr. Linton. One 
of the issues was seated on the spine, just on the boundary line be- 
twixt the sensitive and paralyzed portions of the skin. When the 
spot was touched, it was said almost always to excite the peristaltic 
motion, and this was accompanied by a growling noise The reader 
will here be reminded of the theory of Mr. Teale in regard to the se- 
cretion of air in aftections of the sympathetic ganglia, and of the 
sudden extrication of gas on pressing a tender spot on the spine. Our 
two facts maybe placed side by side, and inferences drawn at the dis- 
cretion of those interested, but on the whole the circumstance above 



312 Waddel on Diseases of the Sympathetic Nerve, 

mentioned seems to confirm the view already taken, that there was 
a highly exalted state of vitality in the ganglia and their cords, for 
no one would have expected such an effect from touching a similar 
spot, corresponding to a sound and healthy ganglion. 

A most important and striking difference between the case here 
on record and ordinary cases of paralysis consisted in this, that 
whereas in common hemiplegia for example, a long time com- 
monly elapses before any emaciation takes place sufficient to distin- 
guish the sound from the diseased limb* in size, there was in the case 
of Mr. H. a rapid emaciation of the lower limbs. (If the reader will 
notice the italicization of the word " rapid" we shall have subsequent 
use for the important fact it expresses.) This palpable departure 
from the usual phenomena of paralysis requires some explanation, and 
the following solution of the difficulty is accordingly offered. The 
muscular apparatus is held under the dominion of the brain and in re- 
lation with it, not by means of the cerebro-spinal nerves alone, but 
also by means of the blood-vessels. If the nervous communication 
be interrupted, the consequence is a loss of sensibility and power of 
motion. The limb, however, still retains its natural size, and its 
nutritive organic actions proceed as usual, because of its vascular con- 
nexion with the great vital centres, the circulation in the vessels being 
maintained in virtue of the energy which they in common with the 
heart derive from the sympathetic nervous system.! Condemned to 
rest, however, by loss of power to move, a limb ceases to invite into 
it the usual quantity of blood, the vessels gradually contract their ca- 
libre to suit this diminution, the nutritive movements all lessen, and 
slow atrophy takes place. Broussais has brought proof that atrophy 
in ordinary paralysis only occurs at all, in consequence of the want 
of exercise. He cites cases of the same slow wasting in limbs which 
are deprived of power to move by other diseases, unconnected with 
paralysis; as fractures, painful rheumatisms, &c. In some chronic 
inflammations of the lungs also, instinct prevents the intercostal mus- 
cles from acting, lest they should aggravate the internal irritation, 
and they hence waste away. Emaciation then, in ordinary paralysis, 
may be safely referred to the continued rest to which the limb is con- 

» Bichat's General Anatomy, Vol. I. p. 218. 

-j- We could scarcely wish for a more beautiful illustration of the separation 
in function of the two great nervous systems, than one to be found in the case 
related by Dr. Parry, in which there was ** a total loss of pulse in one arm, with 
coldness, but complete power of motion; while the other arm was warm, and 
possessed a perfectly good pulse, but had lost all power of voluntary motion." 



Waddel on Diseases of the Sympathetic Nerve. 313 

demned, for lack of encephalo-spinal stimulation.* Why then did 
atrophy supervene so rapidly in the case of Mr. H.? The answer is 
plain. His limbs were condemned to rest, and in that much were 
subjected to the same causes of emaciation which act on other para- 
lysed limbs. But in addition to this, the functions of the arterial and 
nutritive system were most seriously injured in consequence of the 
pathological condition of the sympathetic nerve. How far the re- 
markable diminution in the size of the heart may have depended on 
the same cause, the author will not pretend to say. 

The question may be asked whether the mechanism herein advo- 
cated, can be proven sufficient to account for the occasional and irre- 
gular paralytic symptoms of the rectum and urinary bladder. Those 
two organs have been thought to be much more than any other of the 
internal viscera, subject to the influence of the voluntary nervous sys- 
tem. Dr. O'Beirne has asserted that the rectum even receives nerves 
directly from the spinal marrow, without previous interlacing with 
the filaments of the sympathetic system.t He does not inform us 
upon whose authority the assertion is made, or whether indeed the 
observation is not original with himself. With all due respect for 
the authority of that gentleman, it is impossible to come into the idea, 
in a way so exclusive as his observations seem to require of us. If 
the reader will notice a few quotations from some of the most distin- 
guished of modern anatomists, he will find good reason to demur. 
'*Its nerves," (the nerves of the rectum,) "are derived from the 
solar and hypogastric plexus of the great sympathetic.":}: Again, 
" the anterior branches of the sacral nerves are much larger than the 
posterior. The four first communicate with the sacral ganglions of 
the great sympathetic, besides forming the ischiatic plexus. The 
third and the fourth assisted by the great sympathetic, form the hy- 
pogastric plexus. The fifth and the sixth when it exists, are distri- 
buted to the coccygeus, sphincter and levator ani."§ Thus much 
from professor Horner. " This plexus," (hypogastric,) '^ having a 
compound origin from the preceding plexus," (inferior mesenteric,) 
from the lumbar ganglia and from the trunk of the intercostal nerve 
of each side, is placed like a broad fasciculus between the primitive 

• It is useless to refer the reader to a particular page in the writings of Brous- 
sais for the above principles. Those who are conversant with his works will 
remember them as scattered throughout several. 

f Tlie idea here quoted is used to great advantage by Dr. O'B. in supporting 
his new theory of the anatomy, physiology and pathology of the great intestine. 

t Horner's Special Anatomy, Vol. II. p. 37. 

§ Ibid. Vol. II. p. 503. 

No. XXX.— February, 1835. 27 



314 Waddel on Diseases of the Sympathetic Nerve. 

iliac arteries, descends deeply in the pelvis, and is connected by a 
few branches with the third and fourth sacral nerves: whence a con- 
spicuous interlacing of filaments arise, which in following the bran- 
ches of the hypogastric artery, extend to the rectum, ureter, urinary 
bladder, to the vesiculae seminales in men, and to the uterus and va- 
gina in women."* We quote from one more author. " Its nerves," 
(the nerves of the rectum,) " come from the sciatic and hypogastric 
plexus."t The hypogastric plexus is, according to the testimony of 
all the above-named anatomists, formed by an interlacing of filaments 
^f the sacral ganglia with the sacral spinal nerves, and it then " sends 
its ramifications to the rectum, bladder, &c. along with the arteries 
-which go to be distributed to those parts, "ij: 

The above quotations prove, that though there may be single fila- 
ments going from the spinal cord to the pelvic viscera in a direct 
way, yet the great mass of nervous supply is effected in the usual 
manner; that is to say, the interlacing or anastomoses of the spinal 
nerves with those of the sympathetic system, ha»s a tendency to re- 
move the pelvic as well as the other viscera from the direct influence 
of encephalo-rachidian energy. If there be such a fact in physiology 
as this, that the influences of the two kinds of nervous matter are 
kept distinct after the branches leave the hypogastric plexus to be 
distributed to the viscera, there is but little doubt that it is the func- 
tion of the sympathetic filaments to preside over the peculiar actions 
of the mucous membranes, while the spinal energy is mainly expended 
on the contractile movements of the muscular coats. No great diffi- 
culty can then occur in explaining the partial and irregular paralysis 
of the hollow viscera, (it is of this character in all sorts of palsy,) on 
the same principles which make the causes of general paraplegia in 
the present case so obvious. The insulation of structure and func- 
tion of the different tissues of the same apparatus, renders it quite as 
easy for the sympathetic nerves to appropriate the encephalo-spinal 
aura, originally belonging to one tissue or function, and expend it on 
others, as it would be for them to withdraw this same aura from the 
lower limbs. We had every proof of intense disease of the rectum, 
furnished by autopsy, in the case before us. We found the same ap- 
pearances that we saw in the upper intestines, excepting the perfora- 
tion, and this latter was by no means conclusive of a more intense 
grade of inflammation in the upper than in the lower bowels. It 
pointed to the fact of a more exalted rank in nutritive vitality, and 

* Lobstein on the Sympathetic Nerve. — PancoasVs translation, p. 37, 
f Cloquet's Anatomy. — Knox*s translation, p. 619. 
4 Ibid. 540. 



Waddel on Diseases of the Sympathetic Nerve. 315 

proved the existence of a greater number of absorbents, which ae* 
counts for the ulceration, terminating in perforation. The above 
arguments are brought forward in deference to the assertion of Dr. 
O'Beirne. The author well knows that Bichat has shown, by con- 
clusive physiological experiments, that the rectum and bladder are 
much more under the dominion of the sympathetic nervous influence, 
and much less under that of the brain, than is commonly supposed. 

If the mechanism above stated, of the pathology of this peculiar 
form of paraplegia be correct, it is certainly not confined to the ex- 
planation of one form of disease, but it becomes elevated into a prin- 
ciple, which may be applied to the elucidation of much that is ob- 
scure in general pathology. 

One of the common symptoms of dysentery^ in all probability, has 
its origin in the principle of nervous revulsion here contended for. 
It is well known, that when this disorder has continued for several 
days, there is a weakness of the lower limbs altogether dispropor- 
tioned to the general muscular debility. This is more especially 
felt in the knees after a painful effort to evacuate the bowels, and it 
cannot be better explained than by supposing that at this stage of the 
mucous inflammation, the visceral filaments have become involved, 
and subsequently the principal structure of the sympathetic nerve, 
and that they are now in the act of appropriating a portion of that 
cerebro-spinal nervous principle, which belonged originally to the 
lower extremities. The present ideas of the splanchnic origin of 
paraplegia were communicated to the brother of the gentleman whose 
case forms the basis of this paper, in the winter of 1830. This gen- 
tleman is a physician of distinction, who resided at a distance from 
his brother and the author. He was, at the time mentioned, incre- 
dulous as to the theory proposed. In the fall or winter of 1833, he 
had a protracted attack of dysentery himself, which eventuated in 
such weakness of the lower limbs, that he was for a length of time 
with difficulty able to mount his horse. He has since professed to 
believe that the theory is true. 

The seat of saturnine colic has been supposed to be the sympathetic 
nerve. Passing by the question, as to whether the primary influence 
of lead on the mucous membrane of the digestive tube, consists in 
sedation or not, there can be but little doubt that its eventual effect 
is true inflammation. The irregular state of contraction in which 
the intestines are found post mortem, indicates that an exalted 
vitality of the nerves of their muscular coats had attracted a share of 
the cerebral nervous aura into their structure, larger than usual, and 
which produced those tetanic spasms, constituting the colic during 



316 Waddel on Diseases of the Sympathetic Nerve. 

life. Just such a state of things would seem to have existed, shortly 
after the disease of Mr. H. commenced, (the reader will remember 
the colic for which he was obliged to use such immense quantities of 
laudanum.) When we add to the above named post mortem ap- 
pearances, the traces of mucous inflammation to be found after satur- 
nine colic, we have strong reason to suspect that the visceral nerves 
are involved, and that this disease, (paralysis from saturnine colic,) 
owes its origin to our principle of nervous revulsion. 

The dependence of angina pectoris on the principle herein advo- 
cated, is probably very close. Though Mr. Teale be correct in 
putting this down as a malady of the sympathetic nerve, he is thus 
far from having removed the obscurity which has proverbially en- 
shrouded it, that he has overlooked the cause and cure of one im- 
portant form — namely, that in which the symptoms of angina are 
produced by chronic irritation of the stomach and duodenum. The 
paroxysm commences gradually, and one of the most common symp- 
toms premonitory of the attack, will probably be found to be great 
oppression in the epigastrium, accompanied by hypochondriasis. To 
this succeeds total loss of appetite, eructations of gas, distressing 
dyspnoea, pain and soreness of the left side of the chest, (this latter 
symptom remains frequently for days after the others have sub- 
sided,) pain extending from the left side to the left arm, follow- 
ing the course of the great vessels at the internal edge of the biceps 
muscle down to the elbow, and thence sometimes to the end of the 
little finger. The right arm is occasionally affected in a similar 
manner, but not to so great an extent. The pulse is tolerably regu- 
lar, excepting on the inhalation of a volume of fresh air, and this 
never fails to make it very rapid; but immediately on the collapse of 
the walls of the chest, it again becomes slow, and the difference in 
frequency is so great, that one is apt to be deceived, and suppose 
that there is a complete intermission after the expiration of the air. 
So far as the author's observation has extended, there is no symp- 
tom in this form of anginose disease so constant and unvarying as the 
above-mentioned state of the pulse, and it is most respectfully sug- 
gested to those members of the profession who have under treatment 
cases of gastric irritation, that they request their patients to make 
two or three full inspirations perfectly at leisure, whilst the finger 
rests upon the pulse, that they may observe it. The heart is in this 
case weakened in muscular power, because the energies of the sym- 
pathetic nerve, under whose influence it contracts, are withdrawn 
from it, and transferred to the stomach and duodenum by irritation 
and revulsive action. The plain consequence is an undue accumula- 



Waddel on Diseases of the Sympathetic Nerve. 317 

tion of blood in its cavities, causing oppression, dyspnoea, &c. On 
the expansion of the chest the lungs also expand, and their thousands 
of blood-vessels, great and small, unfold themselves, and from their 
tortuou/s condition become measurably strait, and from collapse be- 
come pervious. In fine, there is a sta>te of things induced in the 
vascular structure of this part equivalent to a vacuum, quoad the 
blood, as much so as the expansion of the chest is equivalent 
to a vacuum, quoad the external airj and if the right ventricle should 
have its contractions facilitated by a more pervious state of the pul- 
monary artery and its branches, the left will, of course, contract 
synchronously. The whole mass of blood finding less resistance, 
flows into its appropriate channels, and permits the heart to contract 
more rapidly. 

It is well known that the opinion here advanced, that the circula- 
tion is quickened during inspiration, is contradicted. The reader 
will take notice that the idea has nothing in common with that of Dr, 
Barry, relative to the effect of atmospheric pressure on the healthy 
circulation. It is a morbid phenomenon traceable to weakened mus- 
cular action of the heart, and is said not to be observable in cases 
where the heart is vigorous, not even when the pleural cavities are 
partly filled with effused fluids. 

Mr. Teale places this disease in the sympathetic ganglia partly, 
and partly in the spinal marrow. He does not tell us that it has 
been introduced by the operation of morbid causes on the gastro- 
intestinal mucous membrane. It has never occurred to the author 
to notice the tenderness in any portion of the vertebral column, but 
even in such a case, a course of diet and regimen, with reference to 
the irritated state of the stomach and bowels, would have been pre- 
ferred to the revulsive remedies to the spine, and this treatment is 
now based on the success which has followed its adoption. An idea 
has likewise been adopted from some conversation with Dr. Malcolm 
Nicholson, a most eminent medical gentleman of Florida, that the 
form of disease above described presents the best opportunity for 
fully testing the virtues of the bark of the wild cherry tree, (Frumis 
Virginiana.) 

It need scarcely be remarked that the pain in the arm in all an- 
ginose diseases is explained by Laennec to result from the anastor 
mosis of the ganglionic filaments with the brachial nerves. 

There has occurred under the notice of the author, the case of aji 
old dyspeptic, who for several years past has been subject to parox- 
ysms, of which the above series of distressing symptoms is an exact 
transcript. When they subside, they are very frequently replaced 

27* 



318 Waddel on Diseases of the Sympathetic Nerve, 

by an obtuse pain in the sacrum or lumbar vertebrae, which is accom- 
panied by a sensation of most uncomfortable weakness of the lower 
limbs. The dyspnoea and anginose symptoms never coexist with the 
debility of the lower extremities, but the two always alternate. 
These manifestation;^ are explicable in the following way. The 
whole tract of the sympathetic nerve is predisposed to irritation. 
This irritation is developed in the stomach by the alimentary mass 
in the first stages of digestion, producing a revulsion of nervous 
energy from the heart, much to the injury of its muscular powers; 
hence the accumulation of blood, dyspnoea, &c. &c. In a later stage 
the faecal mass may produce the irritation in the coecum, colon, and 
rectum, and here the sympathetic nerve by its revulsive power mo- 
nopolizes part of the cerebi o-spiiial aura, which went formerly to the 
lower extremities; hence their present debility. 

Those who hesitate to admit the preceding explanation, because 
all gastric irritations are not accompanied by corresponding affections 
of the heart, are requested to bear in mind the fact long since pointed 
out by Bichat, that there occurs occasionally an interruption in the 
chain of ganglions, effectually putting a stop to the correspondence 
of action between ditferent organs. 

It is without doubt a great fault with medical men, that they fre- 
quently injure the character of the hypotheses which they advocate 
by pursuing them too far. One more disease will be noticed in this 
essay, partly for the purpose of proving that the author is not blindly 
fond of his theory. The sympathetic nerve appears to be sometimes 
subject to a class of diseases entirely opposite in character to those 
of which the preceding pages treat. All our ideas have hitherto 
hinged on the fact, that this nerve is in a state of exalted action in 
many maladies, in which exaltation causes a diversion of nervous in- 
fluence from other organs, leaving them in a state of weakened action 
or paralysis. On the contrary, it seems to be occasionally aff*ected 
with a genuine paralysis of its own functions, or a state nearly ap- 
proaching it. * Death from concussion of the stomach, or from an 
electrical discharge through the abdomen, afford examples of the 
total paralysis. The great oppression of respiration and the inex- 
pressible anxiety attendant on retrocession of cutaneous diseases, 
appear to indicate a partial affection of the same kind. But it is 
amongst miasmatic diseases, in which the miasma appears to have 
an elective affinity for the sympathetic nerve, that we meet the 

* Broussais has devoted a proposition to the proof that paralysis cannot be 
complete in the sympathetic nerve. 



Waddel on Diseases of the Sympathetic Nerve, 319 

greatest number of proofs of this state of disease.* Let us pass by 
the cold stage of intermittent fever to come to the consideration of 
Indian cholera. All epidemics, at whatsoever avenue they approach 
the human system, are first discovered by developing their effects on 
the mucous membranes. In cholera, we have a general indefinable 
malaise, impaired appetite, and great disturbance occasioned by the 
ingestion of food. The vomiting and purging of serous matter is, for 
the most part, a leakage, a transudation from the internal exhalants, 
pointing out a total loss of that nervous energy which we suppose to 
preside over exhalation in health. This function is degraded, in fact, 
from a vital to a physical process; it may be considered a physical, 
but not a physico-vital exosmose. That nervous energy is lost, is 
further proven by the absence of general secretion. There occurs, 
however, a more important category of symptoms than any hitherto 
mentioned, which go to prove a weakened action in the heart and 
blood-vessels, from the paralysed state of the sympathetic nerve. 
These are the oppressed pulse, anxious respiration, thoracic, epigas- 
tric, and abdominal oppression, cold surface, bronze colour, dark 
hue of the blood, indicating deficient exposure to the air in the lungs, 
and total pulselessness. May not the gastro-intestinal redness found 
after death, be a mere stagnation of blood in the internal capillaries 
from the same cause? The laboratory of animal heat, which was 
supposed by Sir Everard Home to belong to the domain of the sym- 
pathetic nerve, appears in cholera to stop its operations; for in addi- 
tion to a state of coldness and sedation almost universal, we have 
presented to us the singular anomalies of a cold breath, a cold tongue, 
and in the latter stages, even a cold epigastrium. 

Such are the proofs of a paralytic state of the sympathetic nerve, 
to be derived from an examination of the organs of nutritive life in 
Indian cholera. We have contended in a former part of this essay, 
that it is in some diseases exalted from the character of a semi- 
conductor to that of a full conductor. It is probable that in cholera 
it is so paralysed, as to lose title even to the character of a semi- 
conductor; for whereas it formerly carried a part of the cerebro- 
spinal nervous principle into the internal organs, it now permits the 
whole of that principle to be expended on those parts of the animal 
economy more immediately under the dominion of the brain and 
spinal marrow. Hence it is, that nervous irritability is so much 
augmented, the senses become acute, noises are agonizing, the skin 
is ultra-sensitive to stimulants, while to the touch of another it ap- 

• Authors make a distinction betwixt miasma or malaria, and the epidemic 
constitution of the air. Both sources of disease are here referred to. 



320 Gerhard's Clinical Reports. 

pears to have lost all vital action. Neuralgic pains occur in various 
parts of the body, and tetanic spasms of the muscles coming on, do 
not even cease with life itself. To all this may be added the re- 
markably clear and undisturbed state of the intellect in the majority 
of cases. 

The practical application of the foregoing thoughts is to Be found 
principally in the former part of the essay, wherein is advocated the 
doctrine of hyper-irritation of the sympathetic nerve. The view 
taken of that doctrine shall not have been communicated to the me- 
dical profession in vain, if it shall have the effect of cautioning one 
single practitioner against the stimulating treatment in nervous dis- 
eases so called. In reference to the distinguished and unfortunate 
gentleman, whose case has here been reported, it only remains for 
the author to express his belief, that mucilage, local bleeding, proper 
counter-irritation, and an appropriate regimen, would have held out 
to him the best prospect of relief. 

Tallahassee, Florida^, June 28^^, 1834. 



Art. III. Reports of Cases treated in the Medical Wards of the 
Pennsylvania Hospital. [Part 1st. Typhus and Remittent Fevers.] 
By W. W. Gerhard, M. D. Resident Physician. 

1 HE Pennsylvania Hospital, at Philadelphia, contains about fifty 
beds for medical patients, besides a much larger number in the sur- 
gical wards, and about one hundred and twenty insane patients; of 
the last mentioned class, about thirty are under medical treatment. 
The number of medical patients is not usually quite large enough to 
occupy all the beds allotted to them, but the service is sufficiently ex- 
tensive to furnish specimens of the disease incident to our climate. 
In the whole year the number of admissions of strictly medical pati- 
ents is between three and four hundred. 

The patients admitted into the medical wards are sailors belonging 
to the merchant vessels in the port of Philadelphia, or mechanics and 
labourers from the city and country. A part of the patients pay for 
their board and medical attendance, as in the French Maisons de 
Sante, but the greater number are admitted on the free list, and are 
supported by the funds of the hospital. The diseases of the seamen 
are usually contracted at sea, or in other ports of the United States 
or of foreign countries, and on this account offer a variety of disease 
not met with in hospitals exclusively appropriated to the poor of a 



Gerhard's Clinical Reports, 321 

single city. The other patients offer the diseases incident to this 
section of the United States. 

The regulations of the hospital exclude all diseases which are ge- 
nerally regarded as contagious, that is,